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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)

2
Puffery
  • 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)
4
Methods
  • 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

5
US 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)

6
US 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

7
US 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

8
Solucients Top 100 Hospitals
  • Identifies industry benchmarks by recognizing
    hospitals that demonstrate superior clinical,
    operational, and financial performance.

9
Selecting 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

10
Solucient 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)

11
Top 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

12
ANCC Magnet Recognition Program for Excellence in
Nursing (1994)
13
ANCC 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

14
Magnet 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

15
Diffusion of Magnetismby year and total number
recognized
16
Creep Overlap - 2001 2003
17
Best, 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

18
Summary Best, Top Magnet
19
U.S. News Best Hospitals - 2003
20
Solucients Top 100 Hospitals - 2003
21
ANCCs Magnet Hospitals - 2003
22
Best, Top, Magnets - 2003
23
Regional 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

24
The 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

25
Solucient 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

26
ANCC 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

28
Comparison of JCAHO HospitalEvaluation Score
Means (2002 JCAHO file)
29
Overall Evaluation ScoresComparative Data - 2002
30
Do 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

31
What 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

32
AHRQ 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/

33
PR 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

34
Research 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

35
Policy 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

36
We are on the job!
  • Stay tuned
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