This is part two of a three part series on the past, present, and future of Grady Memorial Hospital.

In 2011, more than 600,000 patients visited the Grady Health System. Across the Atlanta superstructure's 16 floors and the institution's six neighborhood health centers, 5,300 doctors, nurses, and staff members do everything from refill prescriptions to resuscitate lives. With more than 950 beds, Grady is the state's largest hospital. For Fulton and DeKalb counties' uninsured residents, the safety-net facility isn't simply a mammoth infirmary — it's a lifeline.

Six years ago, Grady nearly closed its doors. Although the 121-year-old hospital has experienced a recent turnaround, it's not out of the woods yet. For this three-part series, CL spoke with more than 50 doctors, patients, administrators, politicians, advocates, and others to learn about the fall, rise, and uncertain future of one of Atlanta's most important institutions.

On a Tuesday evening in February, Dr. Leon Haley Jr. leads about a half-dozen doctors and medical residents through the organized chaos of Grady Memorial Hospital's emergency room. Three hundred and seventy patients flood the facility over the course of the brisk winter night, including 66 distressed men and women anxiously awaiting medical treatment in the waiting room.

During the 12-hour shift, Haley's team zips through austere halls past nurses' stations as orderlies shuttle patients from room to room. Patients toss and turn in their stretchers as they wait for care in the bustling corridors. Ambient beeps resonate from an assortment of machines, occasionally interrupted by a radio dispatch from Emergency Medical Services.

The group discusses the patients, whose ailments range from hypertension to heart failure. One septuagenarian with chest pain remains stable despite the seriousness of the condition. Another nauseated sixtysomething has been vomiting profusely since arriving hours earlier.

In one room, an overweight woman hyperventilates from an asthma attack, gasping for air as a nurse tries to calm her down. The entire scene is a jarring sight to an outsider, but everyone making the rounds carries on with routine precision.

During Haley's 16 years at Grady, he's worked as its chief of emergency medicine, a senior administrator, an Emory University medical professor, and a researcher. Few people know the ins and outs of the 1.87 million-square-foot facility better than he does.

"You have to remember, everything comes through the emergency room department," he says, scanning the room for incoming patients.

As the region's premier level-one trauma center, Grady has earned much of its high standing because of the emergency care it provides. Over the years, though, the hospital has also gained a reputation for shabby accommodations and poor financial management, a fact supported in no small part by the $60 million debt it had accumulated by 2007. But Grady's 2008 privatization and subsequent financial turnaround created the resources needed to improve many departments and boost staff morale.

The public hospital received critical equipment upgrades including new beds, imaging equipment, and trauma bed bays. Doctors that once "MacGyver"-ed their way through procedures saw their departments revamped. Grady's leadership also invested in specialty clinics such as the burn unit and stroke center, which have helped the hospital become a destination institution, rather than only a hospital of last resort.

But the most critical overhaul didn't include cutting-edge technology — it involved recordkeeping. In 2011, Grady installed a new $40 million electronic records system that shaves minutes off a patient's trip to the ER and helps reduce treatment errors. While the change may seem mundane compared to angiogram suites and CT scanners, increased efficiencies can be the difference between life and death. "We measure the minutes because they're so vital," says Dr. Michael Frankel, Grady's chief neurologist. "They make all the difference in the world."

The advances arrived around the same time that the Affordable Care Act threw a wrench into Grady's already precarious financial situation. As part of President Barack Obama's controversial effort to provide Americans with greater access to health insurance, the federal government has linked some hospital funding to patient satisfaction. To earn that cash, Grady's staff must make patients happy — something the hospital's trying to accomplish not only through better care, but also by adding amenities such as gourmet wild salmon to the menu and premium cable in patient rooms.

Grady CEO John Haupert says specialty clinical services and upscale comforts are important, but he stresses that the institution won't stray from its founding mission of treating the poor.

"At a hospital like Grady, one of the ways you do that is to create growth opportunities that help dilute the payer mix," he says. "Not at the sake of the mission, but to sustain and grow the mission."

Today, most conversations about the hospital revolve around financial woes and political turmoil. On the rare occasion that people hear about patient care, it's usually a terrifying tale about a victim passing through the trauma center, or a friend of a friend's horror story from the emergency room. To understand Grady today, CL went inside the 950-bed facility to follow firsthand the varying experiences of doctors, nurses, current and former patients, families, and administrators.

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