Treating the Pandemic’s Shadow: How will the Future of California Health Policy affect Healthcare Design & Construction?

Bill: I’m so pleased to be joined again by Mark Gamble hospital association of Southern California’s chief of advocacy and operations. Mark. Thanks for joining today.

Mark: My pleasure bill. It’s great to be here and great to talk to you again.

Bill: We were so happy to have you again, as our keynote speaker at the AIA healthcare forum.

Bill: And wanted to further that conversation with kinda a deep dive into some of the topics that were covered there. Mark first, the elephant in the room -pandemic. Talk a little bit about what impact that had, and it continues to have on the hospital operation.

Mark: Yeah. Thank you bill.

Mark: And it was great to be back in person after a couple years of being in COVID jail, in the zoom world. But I’ll tell you COVID has cast a long shadow, a long dark shadow and there’s a new dynamic now to the pandemic and I just, for lack of a better term, call it the pandemic hangover. People are angry.

Mark: We see a lot of divisiveness just in the world around us. And we’ve also seen a real uptick in the number of people experiencing behavioral and mental health crisis. Another thing the pandemic put a spotlight on where the health and social inequities.

Mark: Another thing that we’ve also now seen a consequence of the pandemic is the workforce. We have a real workforce shortage. That’s not just impacting hospitals, but healthcare in general. And that’s really added to the dynamic. One other aspect or two other aspects that I’d like to just mention, bill, are the financial hardship that we’ve seen hit our hospitals here in California. And also the fact that they’re still seeing a number of patients. Many hospitals have a very high census of patients who delayed care during the pandemic. And that’s a, another sad consequence of the pandemic.

Bill: Yeah let’s dive into a few of those mark, cuz those are all great topics. You mentioned about the high census. I think we all saw on a day to day basis and cringed a lot of times at the tracking of the number of hospital beds available during. It really shed light the need for some more flexibility in terms of how hospitals can expand when God forbid something like the pandemic happens again.

Bill: It had to be something to watch definitely from your side and think about, solutions for that.

Mark: Yep. And as we talked about at the conference, it really gives the members of AIA and especially the health facilities folks an opportunity to look at how do we design hospitals going forward that are able to expand and expand exponentially.

Mark: We saw at one point in LA county, there were 10,000 inpatients. And I believe I have to check my numbers again, but the number of the capacity is 8,000 and it maybe even lower than that, I’ll confirm that. But we know we had more inpatients than we had beds. And so the system really had to surge.

Mark: And it surged beyond anything. And usually in a disaster, a mass casualty event, there’s mutual aid. So it’s usually an earthquake and you can transfer patients to other counties, other facilities, but this, we saw patients coming up from El Centro. We had hospitals taking patients from other states and we were looking at one point to transfer patients to other states that had capacity.

Mark: Patients were being housed in cafeterias in conference rooms in gift shops. They were being converted to inpatient beds. And so how do you create it? So in a way in these new hospitals that we have to think about going forward, Is there a way to design patient space that’s utilized for something else?

Mark: I do know, obviously there’s CDPH there’s, Oshpod, there’s state regulation. Federal regulations also that need to be considered, but that’s a policy discussion, but it’s also something that maybe the designers and those of you and your business can help think about how we make more flexible spacing.

Mark: Yeah. And even in an earthquake, California hospital associations talked about do you really need the entire hospital to be standing after an earthquake? Or do you need those units that are gonna be critical to caring for patients who are injured in an earthquake?

Bill: Yeah and mark, we’ve seen a couple of things happen there.

Bill: I know some of the facilities as they’re building new parking structures or are spending a little bit extra money and building those parking structures as flat parking structures. So that potentially could be, at least undercover and potentially tended in as well, be additional kind of flex space for them in those type of environments specifically.

Bill: Back to the beds and the utilization. One of, guess what we heard most about was ICU beds and intensive care use beds. And I think one of the other things that we’re seeing, some of the hospitals do, although H Chi haven’t quite caught up with that yet.

Bill: We’re seeing in California, the building of a lot more universal rooms that can be used as flex to ICU beds. Now, currently today, mark, they can’t be licensed as ICU beds because there’s only so many beds that can be licensed as that, but at least there’s that flexibility, for sure. Other things to come to mind with with those kind of couple of comments?

Mark: Yeah. I think the space on a hospital property is critical for a surge, in planning for disasters and mass casualty events, we’ve talked about, okay where are the alternative sites?

Mark: Where are those other sites that we can convert into a hospital? And early on in the pandemic we saw a hospital that was closed down, be reopened and turned into a surge hospital. We saw the LA convention center be turned into a surge and we saw the USS mercy docked in long beach or LA Harbor.

Mark: To accept patients. Very few patients went to those alternative sites because you don’t have the entire infrastructure to support. So to your point, we really need to look at how we utilize that space on a hospital floor or in a hospital parking lot. So I’m really pleased to hear that it’s moving in that direction because of the experiences we had. We saw hospitals set up tents in parking lots and they had to order tents from studios or from studio support companies or entertainment companies. And I think that’s critical as you mentioned.

Bill: It’s so funny, mark. I remember 10 years ago or so the advisory board coming out and saying we won’t need as many beds. Now we’ll need, we’ll continue to need less and less inpatient beds in the future, such that it was really gonna ramp down. And I don’t know what your perspective is. Certainly what I’ve seen is. That’s not the case. Pandemic is an anomaly example, but the aging baby boomers the higher acuity patients that are being seen in those locations, even if we’ve, decanted at some of the services that used to be in the inpatient facility, it just doesn’t seem like the bed need is going away.

Mark: But it is flexing. So prior to the pandemic, census was way down in some facilities. So you had a lot of empty beds, so we can’t build to the demand that you might have in a pandemic or a bad influenza season. So that’s, again, going back to that flexibility in space. And we used to think, as I said, a few minutes ago about alternative sites, which in my mind, those don’t work and aren’t the best thing for the patients or the delivery system.

Mark: So how do you create that flex space? Throughout a hospital? Campus.

Bill: Great point. Great comments for sure. Switching topics a little bit. You’d mentioned at the beginning about. Mental and behavioral health. And I know that’s the demand is tremendous.

Bill: The demands out there, we’ve seen, a backlog of providers that, that we need to be able to provide those services. The mental health them coming in through the emergency room has its challenges as well. What are your thoughts on that side of the, that

Mark: side of the hospital?

Mark: Yeah. And to put an exclamation mark on your last comment, I’ll say a couple months ago was on, I got a call from a hospital emergency department director saying we have and this is a non-psychiatric hospital, so they don’t provide psychiatric services. They had 13 50, 1 50 holds. Those are people who are danger to themselves or others.

Mark: In their emergency department, all of them under the age of 25. And it’s not a big quinary tertiary trauma center, kind of hospital. This was a small community hospital and they couldn’t get those patients moved. Cuz there isn’t the inpatient capacity for a number of reasons. So we really need to spend more time as a society looking at that.

Mark: And we’ve used these words over the years, that mental health parody, where we treat mental health, as we do physical health. And have the resources available throughout the spectrum of care, we’ve really had a decrease in capacity of the inpatient. Beds that are critical in the treatment of people with behavioral, mental health crisis.

Mark: And so we have to figure out how to bring back a continuum that is both the physical and mental health and the consequence of the pandemic that it’s had, not just on the youth, but on adults. Is going to have a long tail. So that’s part of that shadow. I mentioned in the opening comments. Yeah.

Mark: That dark shadow is really going to be the post traumatic stress disorders and how so many people are coping and the lack of social interaction. To be at that conference a couple weeks ago, I had I’m out of muscle memory of standing in front of a group that big in a room, it’s getting reacquainted to that process.

Mark: And I was exhausted afterwards where before, you’re invigorated. But I’m getting back into that social interaction piece. And so there are a lot of people that are grappling with it. And I think that’s, again, going back to the societal issue and also the public policy. And as providers, we have to look at that.

Mark: And then as in again, in your field, trying to tie this back to how do you design buildings that again, maybe flex for that mental health treatment area, but I don’t know how you do that with all the ligature requirements that are out there and are important.

Bill: Yeah, it is really tough because you have so many things that you have.

Bill: To do, to make them safe for mental health patients and right. It is, encouraging when we look in across the United States and we’re doing projects across the United States, that you have large healthcare systems and catchment hospitals that are building.

Bill: Behavioral health facilities, some of them quite large, some of them kind of the outpatient 16 bed facilities like they are doing in the state of Washington that are really putting legislatively, putting a lot of money into those facilities. And I think, it sounds like several of the UC systems are also planning to build.

Bill: Mental health facilities, which is not something that you would’ve normally seen, but I think that’s really an encouraging sign to, to help try to get that, that bed count up.

Mark: Yep. And the governor put a lot of money in his budget towards mental health. So I think we’re gonna catch up Where we hopefully, where we need to be with that with a care integrated care system for the behavioral and mental health aspect.

Mark: Cause we’re certainly seeing an increased demand and we’ve gotta be able to get patients in crisis to a facility that’s outfitted to care for them. Instead of having them languish in an emergency department that does not provide the services other than through an emergency room team. Sure. And yeah that’s something we’re working on with our colleagues and friends at the counties.

Mark: Yeah.

Bill: And, you talk about not necessarily being, the story you told about the community hospital with that many patients in their 51 50 patient. Those workers in there. Obviously there’s a lot of things going on there. The workplace safety must be a a concern as well, given the volume of those of the patients that are going in there that, that have those issues, right?

Bill: Yep. Through the

Mark: pandemic. And again, in that long shadow, we’re seeing a real significant increase in workplace violence. And that’s people coming in who are angry. The hospital staff are telling ’em they have to wear a mask, or we’re saying they can’t have more than one visitor the other things that have happened during the pandemic and now that are continuing on as a public safety piece.

Mark: So we’re seeing staff. Attacked in many in, in, in cases. And so we’re talking to hospitals about, and this is something again for your group. How do you design hospitals that are more considerate of workplace violence and reduce the flow and also to provide more safety aspects in the design and.

Mark: And I’m not sure how we do that, but I think, we’ve looked at we, and we’ve actually had conversations with hospital CEOs. If I go way back in my career, whenever we mention metal detectors, that was, oh, no, I’ll never put a metal detector in here. Yeah. But now it’s becoming more common to hear hospital CEOs.

Mark: Yeah. We’re installing metal detectors. And I think us as society are also getting more accustomed to that. Because we see and hear. Through the 24 7 social media, the increases in violence. And I think so it’s to see a metal detector I used to Ooh, but now it’s safety.

Mark: It’s not a catchall, but it is it’s that safety piece. So for your folks, looking at that safety component, I think is big.

Bill: And we see it in the schools, right? Metal detectors in the schools are commonplace now. You bring up a really good point, especially. On large sprawling campuses to try to maintain that safety aspect and have safety stations, just, my daughter’s in college now and one of the things that she looked at so much, and was so important to her when we were looking at different colleges was, what is their emergency call system and how far a way, do they have to go for that? And of course, on the large sprawling campuses, you’re seeing a lot of those, a lot of money being spent on those type of systems right now. Yeah, exactly. To your point, I think,

Mark: and that’s a great point because my son just went to college and one of the things, every campus we toured, they would point out their blue pillars and say, one would say, you know what?

Mark: You can stand at a blue pillar and you’re gonna see another one, which is the emergency call boxes. For those of you who haven’t been on college campus lately. And I also think, you talk about the large sprawling campuses. Airports are large sprawling campuses and they limit, the entrances and exits.

Mark: We certainly don’t want to get to the point of having a TSA, like screening service at every hospital. But you, we do have to look at key cards and I know many hospitals are already going that route. Just to make sure we’re, the right people are getting through the right doors and not leaving through the wrong doors.

Mark: Yeah.

Bill: So you mentioned, the workplace violence the impacts of angry people on the pandemic that has to be having some effect on the overall workforce as well. And the numbers, that’s probably, we can build as many hospitals as we want, but we also need to be able to staff ’em mark.

Bill: Right.

Mark: so that’s a big issue right now is staffing and again it’s that pandemic hangover, we saw a number of staff who were close to the retirement age, or just young pursue a different career or the older ones closer to retirement retire. And we knew it was coming. Cuz if I go back to my old slide decks from earlier conferences, I’m sure I talked about workforce and the looming shortage.

Mark: The pandemic brought that shortage to us and dumped it on our doorstep here. So now we have it. And one of the issues that we’ve been grappling with our friends in the emergency medical services, arenas, those that the EMS agencies that oversee ambulances they’re having a shortfall.

Mark: They see a shortfall in EMTs. We have a shortfall in hospital staff. So what it’s done is it creates a backlog in the emergency department of ambulances backing up because the hospitals can’t get them off the gurney and into the inpatient setting, cuz they don’t have enough staff to open some beds.

Mark: And then on the backside the skilled nursing facilities have those same challenges. And the ambulance companies that do interfacility transfers aren’t available. So it’s a push pull with our friends in the EMS side. And that’s something that I think we all have to grapple with and how do we increase the pipeline to get the youth and looking at healthcare. And so we’ve got a number of initiatives as other organizations do, trying to increase that pipeline. So for those of you with kids’ age of bill, I encourage him to go into healthcare. I think my son’s seen enough of it that he’s going the other direction through my experience, but yeah, I think it’s important and I do know a number of people whose kids are gravitating towards the medical industry health industry, which is great.

Bill: Yeah. The idea of nurses I think, has been around for a long time, but hearing the graduates for psychology degrees, which we’re not always able to find jobs now are in such demand because of the behavioral health and mental health issues that we’re seeing right now.

Mark: Yep. I have friends with kids who are in crisis and they can’t find a psychiatrist. So that just puts the exclamation mark on our earlier discussion about the needs here.

Bill: Absolutely. I think mark, one of the other observations that I’ve had in some of the policies that have had to be in place because of the pandemic, is that really some of those policies are wrapped into politics and those are affecting not only the hospital workers, but the hospitals and healthcare systems themselves.

Mark: Yeah and I would say it’s the other way around bill it’s politics wrapped around the policy and it’s strangling the policy making that it used to be politics is always driven policy, but now it’s really being driven, at least from my perspective by politics.

Mark: And we’ve seen the local landscape and also the landscape in California become much, much more progressive and even some very progressive friends of mine are saying, wow, they’re being out flanked on the left . I’ve always said it’s important to have a balance and we are certainly outta balance, both at the federal and state and now more so at the and including now at the local level, we gotta get the balance back.

Mark: And so I think those of us on the moderate side, Both spectrums have to figure out how to get policy back front and center. Because we have seen some groups that have become very powerful both again at the state and federal level and both sides of the aisle that really change the dynamics of policy making.

Mark: And that’s put a challenge for us in various industries. And for those of us in healthcare, Seismic’s one of those topics that we’ve struggled over the past couple years to get something through Sacramento on seismic relief because of the politics up there.

Bill: Yeah.

Bill: Let’s talk a little bit about that obviously. Some systems have spent millions, billions of dollars to update their hospitals all the way through the SPC five and everything. And some, see that as a larger financial burden than even just the SPC one steel upgrades because of the dollars associated with that.

Bill: Frankly, having to go into those facilities and shut down certain areas to make those things happen. I can certainly see, both sides of that argument where, you want them safe. You don’t want anything falling on ’em when there’s a, when there’s a an event on the other hand, the impact to operations and impact financially to some of those facilities just seems to make it untenable from a dollars and cents stand.

Mark: And so the balance is, and this is, so around our board table and within our membership it’s why it’s interesting to work for a hospital association that represents all types of hospitals. Cuz you’ve got, as you described, you’ve got the whole spectrum here. You’ve got hospitals that.

Mark: Are well beyond the required MI for the 30 or 2030 deadline. And then you’ve got others that, really they’re on the precipice here. What do we do if we don’t get some more time? And so within that though, the conversation is for those that haven’t gotten to the point where they’re 20, 30 compliant, what does compliance have to look like?

Mark: And that’s part of the discussion CHS having up in Sacramento. And I mentioned it earlier. Do we need, do we really need the entire structure to be standing? You want the entire structure stranding, but we D do we need to be at to that point of the seismic requirements for 2030?. And is there a way that we look at making sure that we have services available that are gonna be critical in the time or in response to an earthquake?

Mark: Yeah. Without cuz if you, yeah. It just, it’s that wing of, we talked about capacity earlier. If there’s not that flexibility and we don’t get some relief, then we’re gonna lose even more capacity in. So that’s part of that dynamic bill where CHHA and our colleagues up in Sacramento of, those discussions will take place up there.

Mark: We’ll support them.

Bill: Can you bring up a great. I don’t know if it’s a disparity or definitely a difference between the urban healthcare facility and the rural healthcare facility. And the fact that, a number one, a number of those hospital districts can’t don’t, can’t afford it.

Bill: Can’t even get the public to approve bonds, to be able to do those improvements anyway. It really puts the that rural healthcare facilities in a very Teno situation, are they gonna get closed down? Is nobody gonna be able to have healthcare there? What, what does that look like at, January 1st?

Mark: Yeah. And it’s also the I’m just making this up. It’s the urban. So it’s the urban hospitals that are in areas that lack the capacity and because they are underfunded. And so this goes back to one of the things I mentioned at the conference is the social and health disparities have were highlighted.

Mark: But something that’s really highlight, been highlighted in my mind through this is the health disparity that’s been created by the underfunding of Medi-Cal. And we’ve. Talking about the short fallen medical reimbursement for years. And it’s only now that connected the dots that Hey, that underfunding has led to a lack of services and health disparities in underserved communities in the urban areas.

Mark: And so you really have urban hospitals that are really important for the Medi-Cal population that are also in that kind of, what do we do around seism. Because all the only source really is Medi-Cal and that’s not enough to create the capital to that you need for that kind of seismic compliance.

Mark: So it’s really now how do we look at that Medi from a different lens? It’s not about will always, me as a hospital it’s will always us for not being able to provide the services, to attract the doctors that we need in our communi. Because the doctors aren’t paid and to the point where they can go out and get commercial contracts and make a living, it’s really hard to make a living on the medical reimbursement rates.

Mark: We’ve all heard the plumber analogy, but there’s a lot of analogies. Now. I think that you see some of these reimbursement rates that are well under what they are to attract the staff.

Bill: Yeah, sure. The disparity obviously with the ESG movement is a huge issue that gets a lot of attention.

Bill: Certainly hopeful that pointing out that will help to solve some of that disparity. For sure. That’s, it’s a Something that’s too bad to hear about.

Mark: Yeah. And I’m encouraged it’s a lot like the quality and safety discussion that took place 25 years ago, 20 years ago where it was, we used to leave that up to the physicians.

Mark: Quality and safety was their issue. But then the hospital said, you know what? No it’s us, it’s our communities issue it’s for all of us. And so we jumped in as an association and we’re doing the same thing now. An organization that we started just prior to the pandemic called communities, lifting communities.

Mark: And it’s an organization that brings hospitals to look at those health disparities social inequities. And how do we work with our colleagues in public health and the communities or the hospitals serve to improve the life aspect of those residents.

Bill: That’s fantastic. And it’s always a pleasure to talk with you. I learned something new every time we talk and so appreciate your time and look forward to having you continue to be our keynote speaker into the future. So thanks again for your time and appreciate your insights that you bring.

Mark: My pleasure, bill. Thank you very much. It’s always great talking to you and I will come back anytime asked.