SFGH also faces other challenges common in the health care industry across the US. Mounting pressures and problems include the growing number of uninsured, the nursing shortage, time constraints to treat patients, inaccessibility to primary care providers, an inadequate supply of staffed hospital beds, rising health care costs and declining reimbursements for services.

Financial support for SFGH has not kept pace with increased costs of health care, which jeopardizes the academic medical center’s quality of care and teaching and reduces the hospital’s ability to recruit and retain health care professionals.

In fact, physicians of all kinds, primary care doctors, psychiatrists and anesthesiologists, cite below-market salaries in an expensive city, burnout from being on call for trauma coverage and sometimes inadequate administrative-academic support as reasons for leaving. The nationally mandated resident work hour restrictions have also resulted in fewer trainees being available to share the workload.

As a result, SFGH is in an extremely fragile condition, Carlisle says.

Of SFGH’s operating budget of $465 million, about 80 percent comes from payments from Medi-Cal, Medicare, other insurance plans, and directly from patients for care delivered by UCSF physicians and allied health care professionals. Less than 20 percent of SFGH’s budget comes from the city’s general fund. Consequently, unlike some public health services, SFGH generates revenue: For every 21 cents allocated from the city’s general fund, the hospital receives 79 cents from other sources, such as federal programs and third-party health care payers.

"SFGH has been chronically underfunded for many years," says Talmadge King, chair of UCSF's Department of Medicine. "We are challenged to provide high-quality patient care in aging facilities with outdated, unreliable equipment. The lack of capital improvements contributes to extended delays in providing needed services and to increasing difficulty in recruiting and retaining qualified medical professionals to work at SFGH."

The Department of Medicine is looking at discrepancies in salaries, among other issues, but the "problem is that we are falling further behind at a faster rate," King says.

Salaries aside, Carlisle says, SFGH officials are most concerned about protecting patient care services. Most critically, she explains, the lack of sufficient funding in the past has threatened SFGH’s designation as a level I trauma center due to inadequate radiology equipment, which is 10 years old. While this crisis has been averted by emergency funds from the city, other shortcomings are still unresolved.

The hospital also has increasingly long wait times for outpatient clinic visits, which are not merely an inconvenience, but also can result in complications and, in some cases, may reduce survival rates, Carlisle says. The wait time for a cancer-detecting colonoscopy, for example, was about a year until SFGH made innovations in scheduling, instituted electronic consultation by the GI service and recruited new GI specialists. Also, waits for elective surgeries can be long because patients with urgent needs get moved to the head of the line as part if SFGH’s triaging process.

Despite the hospital’s budget to operate 302 beds, the census for occupied beds last year ranged from 320 to 340, with 17,874 patients admitted to the hospital over the course of the year.

"These are big problems," King says. "We have quick fixes, but often no long-term strategy."