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US News "Best Hospitals 2004" accounts for nursing magnet status

July 12, 2004 -- U.S. News & World Report's annual rankings of the "best hospitals" now incorporate whether a hospital has achieved nursing "magnet status," as well as its nurse-to-patient ratios. The inclusion of magnet status is a significant step forward. Of course, the role of nursing is still undervalued in these rankings, since these two factors are only small parts of the "other care-related factors" category, which itself counts for just one third of the total ranking in each of the 17 specialties the magazine assesses. The other two thirds consist of physician opinion and mortality data. Nursing opinion is not a factor.

The magazine's methodology summary and the lengthy "complete explanation" (pdf) describe in detail how the rankings are obtained. The methodology was developed and is refined by the National Opinion Research Center at the University of Chicago. The first major category, which counts for one third, is called "reputation," by which is meant reputation among physicians. It is based on the results of a recent random survey by the American Medical Association, which obtained the views of roughly 1,300 physicians as to hospitals they believed to be the best in their respective specialties. There appears to be no measure of the opinions of nurses or any other members of the health care team.

The third, catch-all category of "other care-related factors" includes a wide range of data, most of it derived from the American Hospital Association's 2002 survey of hospitals. These factors are largely measures of a hospital's technology, facilities and programs. The methodology explains (pdf) (p. 14) that the "Nurse Magnet" variable added this year is "a formal designation by the American Nurses Association (ANA) of hospitals that meet specific standards of nursing excellence." Since the National Opinion Research Center seems to recognize the ANA as authoritative, we suggest that the ANA be asked to send out reputational surveys comparable to those the AMA sends, and that the results be given appropriate weight in the final rankings, perhaps as part of the "reputation" category. Nursing is obviously a key factor in some of the other elements of the rankings, notably mortality, but because this is not usually made clear even in the detailed methodology and only physicians are asked their opinions, most consumers are unlikely to realize it.

In a general sense, the mortality category and many of the "other factors" reflect the efforts of everyone on the hospital health care team. But it seems that only physicians are deemed to have valuable knowledge about these efforts, as if they were expert on every aspect of hospital activity, and the views of professionals like nurses, social workers, physical therapists, and pharmacists--many of whom have graduate degrees--count for nothing.

The National Opinion Research Center apparently considers (pdf) (p. 10-11) only the overall number of staff nurses compared to the average daily in-patient and out-patient census. This is a very rough measure of the relative staffing of these hospitals, but there may be ways to make it more precise. The methodology does not consider that some hospitals may focus more on types of units that inherently require more nurses. For instance, ICU patients need more nurses than outpatient clinics. While the major teaching hospitals involved in this survey likely have a similar array of units, there may be some way of accounting for the fact that some hospitals may have somewhat different configurations, perhaps by identifying a core set of types of units that any major hospital would have, and comparing the ratios on a unit-by-unit basis. In a telephone conversation, the lead statistician reported that they are unable to use any better data for the survey because none exists. Apparently the American Hospital Association does not collect unit-by-unit data on nurse-to-patient ratios which would be needed to give this figure more meaning. Without a more meaningful figure, we are reluctant to ask for a heavier weighting on nurse-to-patient ratios.

We applaud the survey's inclusion of nursing magnet status in its 2004 rankings, but urge those responsible to go further to account for the huge influence nursing care has on outcomes in every major area of modern health care. Specifically, we urge those responsible to assign more weight to "magnet status," to improve the use of RN-to-patient ratio data, and to incorporate some measure of nursing reputational opinion, as is done with the opinions of physicians.

See US News & World Report's "Best Hospitals 2004."

The Center has had discussions with the lead statistician of the annual survey, Dr. Colm O'Muircheartaigh of the National Opinion Research Center, for two years running about ways to improve the survey by making it a better reflection of the key role nursing plays in hospital care. He is very open to suggestions for improvement, and is working with us and others toward this end--as evidenced by the inclusion of nursing magnet status, for which we lobbied last year. However, Dr. O'Muircheartaigh notes that progress may be slow in some respects due to limitations in some of the available data related to nursing. If you have suggestions you would like to offer, please email us at and we will put you in touch with the statisticians.

Please post your letters and comments on our discussion board. Thank you.