By Charles Ornstein, senior reporter, ProPublica
Hospitals play key roles in nearly every community. They are economic centers and job engines. They provide preventive and life-saving care. They conduct important clinical research. And they train future generations of doctors and nurses. With strict federal privacy rules and gun-shy PR flaks, it can be difficult to research these important institutions.
Increasingly, data are being published to compare hospitals and other facilities on a variety of quality and patient satisfaction measures. The challenge for us, as reporters, is to determine which measures are meaningful and to contextualize the findings with expert commentary and patient anecdotes.
The response from hospital administrators, especially those with low-rated facilities, is fairly standard: Hospitals are all different, administrators contend, and don’t lend themselves to head-to-head ratings. Many hospitals say their charges are higher because their patients are sicker and require more services. Some also argue they shouldn’t be forced to disclose mistakes publicly because that would discourage employees from reporting problems internally and increase malpractice lawsuits.
Here are some suggestions on how to use publicly available resources, as well as the drawbacks to each of them. Keep in mind that many of these sites rely on hospitals to voluntarily supply their data and depend on them to provide accurate information.
SOURCE: Your state health department
WHAT IT DOES: Licenses and inspects public and private hospitals and nursing homes; investigates complaints involving deficiencies of health and safety codes.
RECORDS: State inspectors do both period institutional reviews (in some cases) and focused investigations based on complaints. Once an inspection is complete, the hospital is given a report detailing the problems found. The report, called a 2567 form or a statement of deficiencies, encompasses everything from nursing shortages and broken chairs to negligent deaths. The institution then files a “plan of correction.” Make sure the copy you get includes the hospital’s response because it can be as interesting–or moreso–than the violations themselves. A review of several years can show patterns of medication errors or nursing lapses etc. or highlight one horrific case. You may want to pay particular attention for reports that include the phrase “immediate jeopardy.” This signals that the problems are serious, and hospitals are required to correct them quickly.
HOW THEY’RE KEPT: The inspection reports are generally kept in regional offices by the name of the institution. You can look through them there (and make copies with a personal copier) or request specific documents via a public records request. Also, if you find a report that interests you, file a request for the back-up investigative notes, an often blunt and detailed account of what went wrong. Click here for a list of state or regional contacts.
DRAWBACKS: Unlike nursing home inspection reports, which rank deficiencies based on severity, hospital inspection reports don’t do this. In fact, if a patient dies, these reports sometimes irritatingly leave it out.
SUGGESTION: Try to make an arrangement with your local health department to receive copies of all hospital inspection reports quarterly. This way you can look for trends and spot problems quickly.
SOURCE: U.S.Department of Health and Human Services, Centers for Medicare and Medicaid Services
WHAT YOU CAN FIND: CMS certifies that hospitals and nursing homes meet conditions to receive Medicare and Medicaid funding. The agency uses state health inspectors to investigate more substantive complaints and investigates whether hospitals illegally dump (uninsured) emergency room patients on other hospitals before they’re stabilized (these are EMTALA violations). If CMS finds a hospital out of compliance, it can cut off Medicare funding—but that almost never happens.
RECORDS: Inspection reports similar to state reports. Reports of EMTALA violations. Threats to cut off Medicare funding.
HOW THEY’RE KEPT: You’ll typically need to file a Freedom of Information request to the regional office that encompasses your facility. State health department offices also often have copies.
If a hospital has been fined for patient dumping, that information can be found on the website of the HHS Office of Inspector General.
SUGGESTION: Once a year, put in a request for all EMTALA violations and look for patterns. Does one particular hospital stand out? Is patient dumping on the rise?
SOURCE: Hospital Compare (www.hospitalcompare.hhs.gov or www.HealthCare.gov/compare)
WHAT YOU CAN FIND: Hospitals provide data on the care they provide patients in five areas: heart attacks, heart failure, childhood asthma, pneumonia and preventing surgical infections. The site displays the average rates for the state and the United States, as well as the rate achieved by the top 10% of hospitals that submitted data. In addition, the site includes patient satisfaction scores for hospitals, as well as data on 30-day mortality and hospital readmission rates for patients with heart attacks, heart failure and pneumonia.
Additional data are available on the use of medical imaging (tests like mammograms, MRIs, and CT scans). NEW: CMS recently added data on hospital-acquired conditions among Medicare patients and Central Line Associated Blood Stream Infections rates. These are found on the Patient Safety Measures tab when you are looking at a hospital. You can download all of the data here.
All of the data sets are updated periodically.
WHY THIS IS HELPFUL: You can download data for all hospitals in your region and find the best and worst in particular areas. Much of the data address process measures—whether a hospital provided recommended treatments for patients with specific illnesses. These measures tell you such things as whether hospitals administered appropriate medications to patients or whether they provided proper discharge instructions, among other things.
CMS offers limited outcome data on the site—whether patients died within 30 days of after receiving treatment there or had to be readmitted to the hospital. Users can find whether a hospital’s rates for its patients with heart attacks, heart failure or pneumonia is better than expected, as expected or lower than expected. Raw data are also available. The data are risk adjusted to take into account the severity of patients’ illnesses and other characteristics. Beware: Nearly all U.S. hospitals perform within expected ranges, so this information may not tell you all that much.
The satisfaction data are based on patients’ experiences at the hospitals. Patients are asked whether nurses communicated well, whether their pain was controlled, whether bathrooms were clean and whether their room was quiet at night. In addition, they are asked for an overall score for the hospital and whether they would recommend it to a friend.
The information on use of medical imaging, hospital acquired conditions and infections, while in its infancy, allows you to begin to explore these issues and write about dangers of excessive imaging and the scourge of hospital acquired conditions.
WHAT’S MISSING: Hospital Compare does not currently provide basic details about deficiencies found during hospital inspections, as it does for nursing homes. It also does not allow users to compare a hospital over time to see if it has improved or gotten worse. CMS plans a major update of Hospital Compare later this year, which will add features and better functionality.
COMPARING HOSPITALS OVER TIME: The Commonwealth Fund offers a Web site to compare hospitals over time and against benchmarks. By creating an account, you can save and share data sets.
HANDS-ON WITH THE DATA: AHCJ has created an excellent primer on how to use the data on patient satisfaction and mortality/readmission. It includes links to Excel files that include up-to-the-minute information on every hospital in the country. Unlike the Hospital Compare site, you can examine all hospitals in your area and you can examine hospitals over time. The patient satisfaction data set (HCAHPS) includes the overall satisfaction ratings for each hospital since the time CMS started publicly reporting this field—a very useful historical barometer.
You can also download the raw data yourself from Medicare’s website. The data are available in either CSV or Microsoft Access. CSV files can be opened in Excel.
SOURCE: Accreditation Council for Graduate Medical Education
WHAT YOU CAN FIND: This organization accredits doctor-training programs run by hospitals. The ACGME monitors a hospital for compliance with resident work rules, examines residents’ scores on board certification exams and looks at the academic credentials of faculty. The ACGME determines the status of individual programs, as well as the institution as a whole.
RECORDS: You can find limited information from the ACGME. Its website tells you the status of each program at the hospital, but sanctions are only listed after an organization’s appeals are exhausted (which can take time.) In addition, the group won’t tell you why a program has been placed on probation or had its accreditation revoked. The website has a link for withdrawn programs, which should be checked regularly.
WHY THIS MAY BE HELPFUL: If your hospital has several programs with sanctions, it could point to a lack of oversight and deeper problems. You may also ask the hospital for the ACGME report or seek a copy from one of your sources. Finally, ACGME keeps aggregate figures for programs on probation and programs that lose accreditation. If your hospital argues that these actions are common, the data can refute that.
FOR MORE INFORMATION: ACGME’s communications director job is currently vacant. For the time being, contact John H. Nylen, Chief Financial Officer,
DATA ON RESIDENCY PROGRAMS: Some specialty groups release data on how many residents pass their certification exams, broken down by individual residency programs. This can be another measure of the quality of a training program. These groups include the American Board of Internal Medicine, the American Board of Pediatrics and the American Board of Surgery.
SOURCE: The Joint Commission (www.jointcommission.org and www.qualitycheck.org)
WHAT YOU CAN FIND: Every three years, the Joint Commission does routine inspections of participating hospitals to ensure they meet the standards required for accreditation. Until 2004, the group gave hospitals a score and also released statistics on how all hospitals in the nation performed. Such scores are no longer available. The Joint Commission also places hospitals in different accreditation tiers—and if a hospital has an overwhelming number of problems, it can lose its seal of approval altogether. If your hospital fared poorly on, say, medication management, you might want to inquire with hospital officials about what happened and how the hospital corrected the problem.
WHY THIS MAY BE HELPFUL: The Joint Commission compiles public reports on each hospital, which are available on the qualitycheck website. These reports include the hospital’s accreditation status, as well as some data on hospital outcomes and practices. (Some of this data is similar to what you can find on the government’s Hospital Compare website.) The Joint Commission site allows the public to filter search results by accreditation status, although sometimes there are no organizations in a state with anything but full accreditation.
LIMITATIONS: The Joint Commission does not release its detailed inspection reports to the public, and many states’ open records laws specifically exempt the reports from public disclosure. AHCJ has called on the group to release these reports. Also, the group rarely takes punitive steps against hospitals, preferring to work with them to improve.
FOR MORE INFORMATION: Joint Commission spokeswoman Elizabeth Zhani at 630-792-5175.
SOURCE: U.S. Department of Veterans Affairs
WHAT YOU CAN FIND: Detailed information on every VA medical center in the country. This includes mortality and readmission rates, surgical quality, satisfaction scores and hospital-associated infections, among other things. The VA has a reputation for its sophisticated medical records system and efforts to measure its care and improve.
WHY THIS MAY BE HELPFUL: Every state has a VA medical center, and the demand for services is growing because of the returning veterans from Iraq and Afghanistan. The data are now available both in PDF format and as data files!
ANOTHER VA RESOURCE: Audits done by the U.S. Department of Veterans Affairs Office of Inspector General, including those about the quality of care at specific hospitals. They can be found here.
The following sources may be useful to add texture to stories on a local hospital but they may not help you generate ideas.
SOURCE: HealthGrades Inc.
WHAT YOU CAN FIND: Using proprietary formulas, this website ranks hospitals in various categories, such as women’s health services and coronary bypass surgery. The site uses a five-star system (with five being the best) to rank hospitals, but hospitals can only earn one, three or five stars.
LIMITATIONS: Some of the data the company use to arrive at its rankings are up to four years old (and they are from the Medicare data set—which does not provide a full view of the patients treated at any hospital). Finally, a review by aYaleUniversityprofessor found that while hospitals rated highly by Health Grades performed better, on the whole, than lower-rated hospitals, ratings on individual hospitals were often misleading. Several reporters have looked into HealthGrades and written insightful pieces about how hospitals pay HealthGrades to use their information as promotion and what the weaknesses of the data are. HealthGrades also makes users pay for detailed reports.
WHY IT MAY BE HELPFUL: Another indicator of hospital quality, particularly if your local hospital treats a lot of Medicare patients.
FOR MORE INFORMATION: HealthGrades spokeswoman Marsha Austin at (720) 963-3848 or email.
SOURCE: Leapfrog Group
WHAT YOU CAN FIND: This group was formed by large employers seeking to improve hospital safety following the 1999InstituteofMedicine Report(“To Err is Human”). Leapfrog’s website lets you know which hospitals are participating in its patient-safety program and how far along they are in complying. It recently released a report on too-early childbirths, including rates for hospitals that voluntarily provided them.
SOURCE: Dartmouth Atlas of Health Care
WHAT YOU CAN FIND: This report looks at health care nationwide and shows that the kind of care doctors give can vary dramatically across regions. Doctors in your area, for example, may favor full breast removal for breast cancer even though studies show a partial removal is equally effective. You can use this site to see if your area has any unusual medical practices. This site is especially useful if you cover one hospital in a large area.
The Atlas team also has released data on how individual hospitals across the country treat patients with chronic illnesses and at the end of life.
FOR MORE INFORMATION OR FOR CUSTOM REPORTS: Contact Eva Folwer at MSL Washington DC at 202-261-2868 or email, or Annmarie Christensen at the Dartmouth Institute for Health Policy and Clinical Practice at 603-653-0897, (c) 802-249-8795 or email.
Finally, here are some other potential sources of information:
Federal compendium of report cards: Compiled by the Agency for Healthcare Research and Quality, it can be found here.
Information on hospital transplants: If your hospital performs transplants, find out characteristics of patients here. This site allows you to look at the number of transplants performed by each hospital and how many patients died while waiting for organs. Hospital specific numbers can be found on the site.
Radioactive materials: Most hospitals use radioactive materials (radiation for cancer patients, for example). If so, they are subject to oversight of the Nuclear Regulatory Commission. Penalties can be found here.
Defaulted doctors: Did your health provider fail to pay back his/her student loans? Find out here.
For research violations: If your hospital has violated the rights of research subjects, you can find out what they did at the Office of Human Research Protections.
Please email Charles Ornstein with any questions or suggestions.
