What makes for a good hospital? Good treatment, of course, is a bedrock. No matter who we are, we all want to get better when we are seriously ill. But do medical responsibilities begin and end with the act of caring for patients? That idea never sat well with Dr. Bernard Lown, the founder of our organization.
Lown was the co-inventor of the modern cardiac defibrillator, a pioneer of coronary care units, a world authority on sudden cardiac death, and a consummate clinician. He was also a champion of the idea that the medical community has a duty to address the health of the wider society. In the 1960s and ’70s, when Lown was a Harvard University professor at the height of his career, there was no greater threat to communal health than nuclear proliferation. This belief drove him to cofound International Physicians for the Prevention of Nuclear War, which was instrumental in opening a dialog between the Soviet Union and the West, and which won the Nobel Peace Prize in 1985.
Lown’s expansive vision of the role of medicine has very much informed the Lown Institute Hospitals Index. American hospitals are justifiably admired for their innovative technology and highly skilled physicians and nurses. Their acute care is second to none. But the health of our nation lags behind every other wealthy country on the planet. One reason is a highly commercialized health care system that forces hospitals to chase revenue to stay afloat—or, as hospital CEOs sometimes say, “No margin, no mission.” That means a focus on filling beds, attracting patients with well-paying (read: private) insurance, and prioritizing high-margin procedures. Uneven quality of care among different hospitals, varying rates of unnecessary tests and treatments, and very different profiles in social responsibility are the natural result.
Existing hospital rankings have examined only one of these aspects of hospital performance—quality—and those rankings have changed hospitals’ aspirations. But we believe that hospitals can and want to avoid unnecessary treatments too. They also want look beyond their four walls to engage more directly with the needs of their communities. What’s been lacking is a context that both expects them to move in that direction and provides them with clear guidance on how to do it. The Lown Institute Hospitals Index put its shoulder to that wheel.
To build our index, we talked to a wide variety of policy experts, physicians, nurses, patient activists, researchers, and hospital CEOs. Everyone said patient outcomes had to come first, so we examined how more than 3,300 hospitals are doing in terms of deaths, readmissions, patient safety, and satisfaction—all widely used measures for patient outcomes. In order to adjust for the different risks of individual patients and their communities, we applied the Risk Stratification Index, or RSI, a machine-learning algorithm in the public domain. After that, we measured unnecessary and inappropriate care using proven data methods, applying them for the first time to individual hospitals.
Everyone we spoke with encouraged us to find ways to measure hospitals’ fulfillment of their social mission, or what we call “civic leadership.” This was more difficult. The Internal Revenue Service requires nonprofits to disclose how much they spend on “community benefit,” such as charity care, which comprises one aspect of civic leadership. But the reporting is patchy, and much of what is reported seems barely to meet the intent of the rule. We took this all into consideration.
We also measured the ratio of hospital CEO pay to worker pay, a yardstick in other industries for fairness and corporate citizenship. Inequality is a powerful factor in determining health, and as the largest employers in many locations, hospitals’ pay equity can have an impact on the health of the entire region. To the best of our knowledge, this ratio has never before been reported for hospitals.
Finally, we invented an entirely new metric, which we called “inclusivity,” to identify hospitals that do an especially good job of caring for all the people in their area. This metric shows the degree to which a hospital’s patients reflect the demographics of the community around it and allowed us to acknowledge hospitals that welcome people regardless of income, education, or race. (For more information, see our methodology.)
The actual number crunching, using a huge range of data sets, has been a two-year odyssey that has taxed the resources of a very small organization. We’re thankful to have had the Washington Monthly as a thought partner during the development of the Lown Institute Hospitals Index and are grateful that they used it to power their rankings. The fact is, some hospitals are “doing it all,” performing well on patient outcomes, civic leadership, and avoiding overuse. Based on our conversations, we believe that most, if not all, hospital leaders and staff want to succeed in each category. The Lown Index points the way forward and creates a fresh set of expectations for the health system Americans both want and need.