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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,

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Presentation on theme: "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,"— Presentation transcript:

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)


4 Methods 1. Solucients Top 100 Hospitals 2. US News & World Reports Best Hospitals 3. 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 (n=20) 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 1. Management philosophy & practices 2. Adherence to standards for improving the quality of care 3. 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 Magnetism by year and total number recognized

16 Creep & Overlap - 2001 & 2003 Designation20012003 Best173203 Top101 Magnet4791 Best & Magnet1425 Best & Top1513 Top & Magnet212 Best, Top & Magnet 16

17 Best, Top, & Magnet 1. University of CA Irvine 2. Poudre Valley Hospital, Fort Collins CO 3. Mayo Clinic, Rochester MN 4. NC Baptist, Wake Forest Un., NC 5. Methodist Hospital, Houston, TX 6. Inova Fairfax Hospital, Falls Church VA

18 Summary – Best, Top & Magnet Best (14yrs)Top (11yrs)Magnet (10yrs) Measurement Framework norm referenced criterion referenced Focus structure, process, outcomes outcomesstructure, process Self-nomination no yes Self-appraisal no yes Site visit no yes Nursing yesnoyes Purpose inform consumer choice excellence in management excellence in nursing care Empirical evaluations 334

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 1. CHEN et al., 1999 AMI patients over 65 Significantly lower LOS and costs than rest No significant difference in mortality rates 2. Griffith & Alexander 2002 Found that 8 of the Solucient measures of hospital performance were valid and reliable 3. 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 Hospital Evaluation Score Means (2002 JCAHO file) Hospital Typemean score SD All Community Hospitals (Federal, psych and other specialties eliminated) 90.844.43 U.S. News Best 91.663.68 Solucient Top 100 93.133.05 ANCC Magnet Hospitals 94.431.27 Hospitals with Multiple Designations 96.342.04 JCAHO Commended 96.941.61

29 Overall Evaluation Scores Comparative 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.

33 PR Bonanzas Americans have a love affair with rankings. Public relations goldmine Marketing campaigns News media pick up Web-sites Get a 2 nd 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 accountable…need accurate measures. (Devers) How to uniformly gauge quality? Some argue that public does not understand or will not use…the 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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