Early next year a mammoth hospital that aspires to become the pride of Europe will open in Paris. Long enamored of grand gestures, the French government has poured unparalleled talent and resources into this crystal palace just a stone's throw from the River Seine.
The Hopital Europeen Georges Pompidou intends to showcase the very latest thinking in every aspect of French healthcare. It will use electronic medical records, a paperless workflow and a novel administrative framework; emphasize outpatient treatment; and provide care that is far more comfortable and efficient. It's also going to be a home for the most advanced medical teaching and research in France.
Yet the project's reach may have exceeded its grasp. The hospital is over budget and overdue. In fact, the Georges Pompidou Hospital could well become the Denver International Airport of the French healthcare system.
Behind schedule. Pompidou hospital has been under construction since Nov. 15, 1993, when President Jacques Chirac laid a Plexiglas cornerstone encasing a laserdisk. It was supposed to open in 1998 at a cost of $258 million for construction alone, says Didier Vallens, who is in charge of medical equipment for the new hospital.
Last July, when MODERN HEALTHCARE| toured the very rough construction site, it was scheduled to open in January 2000. But since then, the opening date has been pushed back to March 2000.
The 1.3 million-square-foot building is now budgeted at $300 million, plus $17 million for information systems and $50 million for medical equipment, logistics and furnishings.
Traditionally, healthcare in Paris has been delivered in walled compounds of 19th-century buildings barely visible from the street. The new hospital will replace three aging structures nearby operated by the government's district healthcare authority, Assistance Publique-Hopitaux de Paris (AP-HP), which is responsible for all of the region's 45 public hospitals.
Combining the three older hospitals-Broussais, Boucicaut and Laennec-will reduce the total bed count to 857 from 1,200, and staff will drop to 2,500 from 3,500.
On its World Wide Web site (www.hbroussais.fr/HEGP/), the new hospital promises to "open itself to the city." Accessed by vast entryways, the complex is aggressively modern, with three steel-and-glass towers intersected by a pedestrian walkway nearly a quarter-mile long and four stories high. The walkway, roofed with glass and traversed by skybridges, carries patients to such amenities as a newsstand, a florist, a hair salon, a cafe, an employee day-care center, a nursery for visitors, a gym and a 400-seat theater and conference center for medical researchers.
Soon a commuter rail stop a block away will make the hospital even more accessible to the public.
Improving service. Clinically and administratively, the hospital aims to introduce accountability and a service-improvement mentality to the government-run system. It will consolidate care into three "axes" of activity-cardiology, oncology and general care, including emergency services, trauma and ambulatory surgery. Each axis will have 250 beds.
To facilitate efficiencies, clinical departments will buy services from one another, and a speedy in-house laboratory will service other hospitals and clinics. A separate administrative sector will oversee food services, pharmacy, central sterilization, technical support and logistics.
A system of contracts and internal billing is being prepared but is not yet operational. "This is a new thing in French hospitals," says Vallens proudly. "The purpose is to improve the quality and cost of service, to give back to caregivers their principal tasks of giving care."
Each floor of the new structure will have its own director of services to make sure everything works right and a hotel coordinator to make sure patients' needs are met.
Although the vast majority of beds are intended for inpatient stays of several days, the hospital's administrative and physical design should easily support the shift toward ambulatory care. Planners installed the latest equipment in an attempt to automate processes such as laboratory testing and included an information system that will deliver test results directly to physicians.
Just another showpiece? The hospital follows in the series of great public works projects of the past 15 years in the heart of Paris. The Grand Louvre, the new finance ministry, the Library of France, the Grande Arche de la Defense, the Bastille Opera-all are signature showplaces designed to project an image of France as dynamic, forward-looking and hyper-modern. Some wonder whether the hospital is just another showpiece or whether it will indeed transform care.
"It was something like building the pyramid, the Eiffel Tower," says Yves Charpak, president of the Paris consulting firm Eval. "And it was not based on any evaluation of the need for hospital beds and the need of the population. In Paris we have too many hospitals, too many beds, too many medical university doctors."
France is the most overbedded country in Western Europe, if not the world, with one bed for every 86 residents. Germany has one bed for every 130 people, and the U.S. has one for every 243.
Critics say hospitals and clinics haven't followed as people move to the suburbs. They note that the population of central Paris, now 2 million, is decreasing. "The joke is, each morning the commuter trains are filled with patients, doctors and nurses, heading to Paris to have blood drawn," says Isabelle Durand-Zaleski, M.D., who runs a public health department at Hopital Henri Mondor in Creteil, a Paris suburb. She added, "At my hospital, everybody thinks the Pompidou is a waste of money."
Critics also say the hospital's location was motivated by politics. The mayor of Paris is the titular chief of the regional health service, which employs 80,000 people and commands an annual budget equal to $4.3 billion. Some of those employees live in apartments owned by the AP-HP, and certain top managers benefit from rent-free dwellings.
Construction miscues. As in any large hospital project, there have been setbacks. A room that was intended to hold two computed tomography scanners proved too small; now there will be only one. Some ceilings were too low for other large pieces of equipment and had to be torn out and redesigned. There's a room for a second magnetic resonance imaging scanner but no budget for it. The room will remain empty for the time being.
"There were some errors of conception," Vallens says.
As chief engineer, Vallens has to manage a thorny problem. His equipment vendors are growing impatient. French government purchasing rules decree that vendors cannot be paid for equipment until it is delivered and installed. However, the equipment can't be delivered until the hospital is ready. "They're sitting on the equipment with no payment," he says with a wince.
The hospital's opening has been postponed several times because of construction delays. In March 1998 the contractor for the white aluminum-paneled exterior declared bankruptcy, which halted the project for months, leading to a cascade of complications. But those are minor issues compared with the big questions that surround this colossal enterprise.
And a plan to partly finance the Pompidou hospital through sales of AP-HP land holdings has gone awry because parts of the old hospitals were placed on a register of historic buildings, drastically reducing the value of the land to potential developers, Charpak says.
The bulk of financing was borrowed by the AP-HP, with the balance to be funded with proceeds from the real estate sales, Vallens says.
Some say the AP-HP's structure, supported by an entrenched bureaucracy, will sabotage efforts to maximize efficiencies. For example, funds are allocated to facilities on the basis of bed counts rather than the volume and intensity of services. Physicians, determined to maintain authority over small fiefdoms, have resisted consolidating inpatient units, Charpak says. In a compromise, Pompidou's director general decreed that no department would have fewer than two beds, Durand-Zaleski says.
A prospective payment system is on the horizon. "Until we have a new financing system, it will be very difficult . . . to document the tasks and procedures to internally bill," Durand-Zaleski says. "You have to have the old guard die out before it comes to that."
Can the hospital ever meet the grandiose expectations set for it? "It will in time," Durand-Zaleski says. "I think it's a beautiful tool."