Title: The public is concerned about hospital quality but has less information about selecting a hospital t
1- The public is concerned about hospital quality
but has less information about selecting a
hospital than they do when purchasing a toaster
or a car (Malone, 1999) -
2Puffery
- representation, statement, or conduct that
clearly over-exaggerates - is not intended to be an offer to be relied
upon. - Consumer protection
- (2000 Legal on-line Dictionary)
3(No Transcript)
4Methods
- Solucients Top 100 Hospitals
- US News World Reports Best Hospitals
- American Nurses Credentialing Centers Magnet
Recognition Program - Descriptive statistics
- Spatial mapping
- Review of empirical literature
5US News World Reports Best Hospitals
- If you are looking for the best in medical
care - web-based guide.
- designed to assist you in your search for the
highest level of medical care. - (US News World Report)
6US News Selecting the Best
- National Opinion Research Center
- Each July since 1990
- Ranked by specialties (17)
- Only rigorous assessment of all US hospitals
- Eligible -- tertiary care hospitals
- COTH membership or
- Affiliation with medical school or
- Availability of 9 out of 17 prescribed
technologies - Hospital Quality Index (HQI)
- Honor Roll score well in at least 6 specialties
7US News continued
- Measures produce HQI
- Structure AHA Annual Survey data
- FTE on-staff Nurse to bed staffing ratios
- Services available (technology index)
- of specialty-specific technology services
- Process (proxy measure)
- Physician nominations
- Newest specialties reputation only
- Outcomes
- Medicare risk-adjusted mortality by specialty
- Pool most recent 3 years
- Mortality ratio inpatient deaths/expected
8Solucients Top 100 Hospitals
- Identifies industry benchmarks by recognizing
hospitals that demonstrate superior clinical,
operational, and financial performance.
9Selecting the Top 100
- Since 1993 -- December
- Management results that separate these hospitals
from the pack. - Which hospitals offer superior care at lower
costs. - Data obsession--common trait.
- Enterprise benchmark reports for purchase
- Eligibility restricted 5 categories (n20)
- Overall select specialties (ICU, CV, Ortho,
Stroke benchmarks) - Data source Medicare Cost Report
10Solucient TOP 5 strata
- Major Teaching (400 or more beds resident to
bed ratio of at least .25) - Teaching (at least 5 residents or resident to bed
ratio of .01-.24) - Large Community (250 or more beds)
- Medium Community (100-249 beds)
- Small Community (25-99 beds)
11Top 100selection
- Ranked by strata on following measures20 best
rankings per strata selected - Financial management
- Expense/adjusted discharge case mix and wage
adjusted - Profitability
- Proportion of outpatient revenues
- Index of total facility occupancy
- Clinical performance
- Medicare risk-adjusted mortality index
- Risk-adjusted complication index
- Operational performance
- Severity-adjusted average LOS
- Case-mix and wage-adjusted expense per discharge
12ANCC Magnet Recognition Program for Excellence in
Nursing (1994)
13ANCC Recognizes excellence in 4 target areas
- Management philosophy practices
- Adherence to standards for improving the quality
of care - Leadership of the CNO in supporting professional
practice and continued nursing competence - 4. Attention to the cultural and ethnic
diversity of patients, their significant others,
and providers
14Magnet Recognition Process
- Self evaluation ANAs Scope Standards
- ANA quality indicator data (NDNQI)
- Site visit
- Community input
- Could range from 30,000 - 75,000
- Reevaluated every 4 years or more often with
leadership change - Continuous Process submit data annually
15Diffusion of Magnetismby year and total number
recognized
16Creep Overlap - 2001 2003
17Best, Top, Magnet
- University of CA Irvine
- Poudre Valley Hospital, Fort Collins CO
- Mayo Clinic, Rochester MN
- NC Baptist, Wake Forest Un., NC
- Methodist Hospital, Houston, TX
- Inova Fairfax Hospital, Falls Church VA
18Summary Best, Top Magnet
19U.S. News Best Hospitals - 2003
20Solucients Top 100 Hospitals - 2003
21ANCCs Magnet Hospitals - 2003
22Best, Top, Magnets - 2003
23Regional dominance Pockets of excellence ??
- High preponderance northeast, south
- 6 states empty
- Mountain, west north central, west south central
regions - Some states in highly designated regions had
fewer hospitals than those in the empty regions
- CA -- 450 hospitals (3 magnets) .7
- NJ 74 hospitals (14 magnets) 19
24The US NEWS Best -- 3 Empirically based
publications
- Different rankings when different decision models
used (Teasley, 1996) - CABG outcomes in PA and NY (Hartz et al., 1997) -
Best did not perform better than rest - Significantly lower AMI mortality rates (Chen
et al. (1999) - Clinical practice processes
- Asprin beta blockers
- Numerous reports of methodological flaws
conceptual issues - What is examined
- Who does the nomination
- best colleges
- best party schools
25Solucient Top -- 3 empirically based
publications
- CHEN et al., 1999
- AMI patients over 65 Significantly lower LOS and
costs than rest - No significant difference in mortality rates
- Griffith Alexander 2002
- Found that 8 of the Solucient measures of
hospital performance were valid and reliable - Griffith, Knutzen Alexander, 2002
- a disjuncture between Top outcome measures
and JCAHO evaluations in non-federal hospitals
26ANCC Magnet Hospitals 4 Empirically based
publications
- Aiken, Havens, Sloane, 2000
- support for nursing practice
- nurse reported quality
- nurse satisfaction
- better nurse staffing ratios
- more highly educated nurses
- nurse burnout
- Havens, 2001
- strong departments of nursing
- quality ratings
- organizational support for nursing practice
- difficulty recruiting nurses
- patient and family complaints
27- Upenieks, 2002, 2003
- nurse satisfaction in ANCC magnet hospitals
-- linked to stronger nurse manager leadership - levels of RN reported empowerment
- Havens, (Forthcoming)
- use of outside nurses
- vacancy rates
28Comparison of JCAHO HospitalEvaluation Score
Means (2002 JCAHO file)
29Overall Evaluation ScoresComparative Data - 2002
30Do JCAHO scores contribute to designation?
- No statistically significant differences between
designated hospitals and the rest on JCAHO scores
(t-test) - Logistic regression models of designation (does
JCAHO score predict designation or not?) - Unrelated to receiving best, top, or magnet
- Higher JCAHO scores only slightly (and not
significantly) predict being designated. - Model fit is poor.
- Havens, Vasey, Kellogg 2003,
- Unpublished
31What is the take home?
- Concern about the quality of hospital care
- Adverse events and staffing deficiencies cause
alarm - Scant information to assess performance
- No universal, consumer friendly measure of
quality - Growing of ratings / rankings
- Competition and marketing campaigns
32AHRQ advice re selecting quality care
- Look for a hospital that
- Is accredited by JCAHO.
- Is rated highly by the state, consumer groups, or
other organizations. - http//ahrq.gov/
33PR Bonanzas
- Americans have a love affair with rankings.
- Public relations goldmine
- Marketing campaigns
- News media pick up
- Web-sites
- Get a 2nd opinion from the best hospitals
- Helps our development efforts
- US News hottest marketing tool in the
healthcare industry - Financial boon for awarding organizations
- And .more
34Research Implications
- Paucity of research
- Mixed findings
- Are the Best really better than the rest?
- Are some of the best better than other bests?
- Best on what?
- Is this meaningful to consumers - The big picture
paradigm? - Reliance on structure and process only
- What are the key questions?
- Safety
- Patient perspectives
35Policy Implications
- A case for moving research to inform policy
- Consumer info, mis-info, or dis-info?
- As competition growsrelease of comparative
information will increase - Desire to hold healthcare organizations
accountableneed accurate measures. (Devers) - How to uniformly gauge quality?
- Some argue that public does not understand or
will not usethe public is requesting - top 10 is part of American culture
- How to depoliticize big maker for magazines
- Use of e-health sites is growing
- Being touted as a decision guide for consumers
- Web sites
- Ladies Home Journal
- Readers Digest
36We are on the job!