Nonprofit hospitals, more nurses and greater availability of technology equal better patient care

Federal and military hospitals also receive top quality grade

BOSTON Patients are more likely to receive high quality of care in not-for-profit hospitals and in hospitals with more registered nurses and advanced technology, reports a comprehensive Harvard Medical School (HMS) analysis published in the Dec. 11 Archives of Internal Medicine.

Bruce Landon, MD, MBA, associate professor of health care policy at HMS, and colleagues found that overall, not-for-profit hospitals consistently performed better than for-profit hospitals when it came to delivering high-quality care for three common medical conditions: congestive heart failure (CHF); heart attack (acute myocardial infarction, AMI); and pneumonia. Hospitals with higher registered nurse staffing levels, more advanced technology, and federal or military designation all had high performance.

"Our study is the first to comprehensively examine the characteristics of hospitals that are associated with higher quality of care for these three important medical conditions," said Landon, who is also an associate professor of medicine at HMS and Beth Israel Deaconess Medical Center.

This study assessed the quality of care for CHF, AMI, and pneumonia in more than 4,000 hospitals in the U.S. that reported data to the Joint Commission on Accreditation of Healthcare Organizations or the Center for Medicare and Medicaid Services. Since the Medicare Modernization Act of 2003, hospitals have been required to report their performance on 10 measures in the areas of CHF, AMI, and pneumonia in order to receive their full Medicare payment update. The study also examined what hospital characteristics (such as ownership, size, location, teaching status, and proportion of Medicare or Medicaid admissions) were associated with high-quality performance.

In addition, the authors created an index to assess how the number of registered nurse staffing levels affected quality of care. Hospitals with more registered nurses performed better on all quality measures, however, licensed practical nurse staffing was associated with lower performance. Nurse staffing levels were calculated as the average number of hours of care by a registered nurse or a licensed practical nurse per inpatient day. This measure was derived by adjusting reports of nurse staffing levels by the average inpatient census at each hospital.

"Nurses, as the primary caregivers for hospitalized patients, provide a crucial link between doctors and patients," says Landon. "Our study supports the importance of adequate nursing care to the quality of treatment patients receive."

Overall, 76 percent of patients hospitalized with CHF, AMI, or pneumonia received recommended care. To assess this, Landon and colleagues evaluated how many patients received appropriate care across all of the measures for the three medical conditions.

Not-for-profit hospitals consistently performed better than for-profit hospitals for each condition, and federal and military hospitals had the highest performance. "Because a large portion of federal and military hospitals are part of the Veterans Health Administration, this suggests that lessons learned from their decade-long experience in quality improvement deserves further study," said Landon. "It seems likely that the information technology and computerized reporting systems at the VA contributed to their high performance."

Hospitals that served greater proportions of Medicaid patients had low quality of care across all conditions studied. Hospitals in the Midwest and Northeast, not in rural areas, had better performance, as did hospitals with more advanced technology available.

Landon and colleagues also performed analyses that examined the relationships between the various quality measures. This analysis suggests that rather than examining quality by disease (e.g., AMI, CHF, or pneumonia), it might be more useful from a quality improvement perspective to examine quality measures according to functional roles in the hospital. They created composite measures in the areas of treatment and diagnosis and counseling and prevention as well for each of the three diseases, but found that quality varied more by functional roles in the hospital than by the particular disease being treated.

"Therefore, efforts to improve quality in hospitals should focus on core competencies that can improve care across multiple diagnoses," said Landon.


Harvard Medical School has more than 7,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 18 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, The CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, VA Boston Healthcare System.

Last reviewed: By John M. Grohol, Psy.D. on 30 Apr 2016
    Published on All rights reserved.