Why Nurses Leave the Bedside; A Bedside RN's perspective
Produced with the considerable assistance of Webmistress Pye
Topic: Hospitals and Hospital Stats,
part of the ChapterThe Health Care Industry and Nurses Within It [See Chapter TOC]

Hospitals comprise the largest employment venue of America's Nurses [See Nursing Employment Setting Graph]. America is experiencing a conversion towards for-profit hospitals. See [Ascendancy  of For-Profits dedicated page] 

In 1980, about 1 hospital patient in 7 stayed overnight. By 1990 that had dwindled  to 1 in 10 and by 2000 to 
a scant 1 in 16. YS New Best Hospitals Methodology [The Importance of this statistic to Nursing involves the Accuity of the Patients involved in her work load, and the increasingly difficult arena of her job environment]

 "There are over 6,500 hospitals in the United States. The majority of them are 'general' hospitals set up to deal with the full range of medical conditions for which most people require treatment. But more than 1,000 hospitals  specialize in a particular disease or condition (cancer, rehabilitation, psychiatric illness, etc.), or in one type of patient (children, elderly, etc.)."2 See Footnote two The Statistics Provided In this Page are dependant on the American  Hospital Association's Annual Survey, and includes hospitals that are registered in that organization 
[5,801 of the over 6,500 mentioned above].


 This Page Table of Contents:


How Hospitals are Accredited: JHACO and Magnate Hospital Accreditation
From a Bedside RN Perspective, the Magnate Hospital accreditation is the more important, and only truly accurately revealing accreditating tool

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [A General Accreditation]
Hospitals do not have to be JHACO certified, but most seek that status. "The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is  an independent, nonprofit organization which conducts a quality assessment of about 80 percent of all hospitals in the United States every three years. The Joint Commission accredits more than 5,000 hospitals and  over 6,000 other health care facilities, including outpatient surgery, home care, long term care and mental health care organizations. Hospitals do not have to be accredited by JCAHO to operateóthe accreditation process is entirely voluntary. Accreditation by the Joint Commission means that a hospital meets at least minimum standards of quality. JCAHO rates hospitals in 28 different performance areas, including assessment of patients, medication use, operative procedures, patient rights, staff, laboratory and emergency services, infection control and social  services. Of the hospitals accredited by JCAHO, 90 percent have Accreditation with Recommendations for Improvement, meaning the hospital generally meets the standards, but does not meet certain important standards in at least one important area..".2

The truth about JCAHO is itself worthy a study. JCAHO must continue to promote its own use, and so must constantly find dificiencies then requiring a re-review. In so doing they often create cumbersome and unwieldy "hospital Practice Standards" which greatly affect the nursing personnel that are the primary labour resource of any hospital. Despite the fact that the intent of many of these standards is positive for the patient, the actual implementation can require the need for support services and resource tools not available to the hospitals surveyed, or the persons working therein, thus contributing to the "downward slide" of all tasks and responsibilities to the bedside practitioner, the nurse, adding to her distress and daily workload. In addition, having worked many years in hospitals, and home care agencies, I can attest to the more fluid ability to meet the "standards" and the improved [but temporary] interlacing of support services in  any hospital or home care agency during the time just before and during a JCAHO survey, causing the sruvey to be perceived as superflous and fantastical by the persons employed within the entities they survey. Currently, though, JHACO is at long last changing the "Always announced" visits which have marked its history, and will now begin "Unannounced Visits" which are more likely to improve the perception of their accuracy to the persons working within hospital systems.

Magnate Hospitals Accreditation [a NURSING SERVICE reliant accreditation]
Currently, there is an vigorous attempt to identify, catalogue, and promote hospitals of  Magnate Status. ""The label 'Magnet hospitals' originally was given to a group of U.S. hospitals that were able to successfully recruit and retain professional nurses during a national nursing shortage in the early 1980s. Studies of Magnet hospitals highlight the leadership characteristics and professional practice attributes of nurses within these organizations... Hospitals selected met the following criteria: 1) nurses within the hospitals considered them good places to practice nursing, 2) the hospitals had low turnover and vacancy rates, and 3) the hospitals were located in areas where there was significant regional competition for nursing services." (JONA, January 1999) These "nurse friendly" organizations benefit from reduced costs due to low turnover, which results in greater institutional stability." The American Nurses Credentialing Center
Magnate Status reference is becoming increasingly utilized in legislation affecting hospitals and their access to government funds,  providing economic benefit to those hospitals meeting that status and thus encouraging the trend towards accreditation as a Magnate Hospital.
THERE ARE only 79 HOSPITALS of the nations more than 6500 who have Magnate HOspital  Status
[as of Sept 2003]


STATS on American Hospitals:
Total Numbers, Types, Total Beds in America, Non-profit vs for-profit numbers, and network and system inclusion numbers.
The following is relevant to The American Hospital Association Survey. There are over 6,500 hospitals in the United States. Registered Hospitals as mentioned herein refers to those hospitals that meet AHA's criteria for registration as a hospital facility, thus the number of hospitals in this study does not include the entire number of hospitals in the United States
.
"There are 5,801 registered hospitals in the US, and 987,440 Total staffed beds in all US registered Hospitals [The American Hospital Association 2001 annual survey]  4,901 of which are Community [nonfederal, short-term general, and other special hospitals]  ... Other special hospitals  include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are nonfederal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries.] , Of this 4 901,  2,998  are not for profit, and , 754 of which are For Profit, and 1,156 are state and local govt community hospitals. The remainder are federal hospitals, Nonfederal Long Term Care Hospitals  and Hospital Units of Institutions (Prison Hospitals, College Infirmaries, Etc.)" AFA-the national advocacy organization for investor-owned hospitals and health systems [American Federation of Hospitals]
Hospital Stats
The following information is from the Mississippi Hospital Association, citing " the 2001 annual survey...a sample of information found  in Hospital  Statistics, 2003 edition. The Source [Mississippi Hospital Association] states that " The American Hospital Association 2001 annual survey (The definitive source for aggregate hospital data and trend analysis, Hospital Statistics includes current and historical 
data on utilization, personnel, revenue,expenses, managed care contracts, community health indicators, physician models, and much more.) . Hospital Statistics is published annually by Health Forum, anaffiliate of the American Hospital Association. Additional details on Hospital Statistics and other Health Forum data products are available at ]www.healthforum.com. Hospital Statistics 2003 edition." 
  • Registered* Hospitals

  • 5,801
  • Number of U.S. Community**Hospitals

  • 4,901
  • Number of Nongovernment  Not-for-Profit Community Hospitals

  •   2,998
  • Number of Investor-Owned (For-Profit) Community Hospitals

  • 754
  • Number of State and Local Government Community Hospitals

  • 1,156
  • Number of Federal Government Hospitals

  • 243
  • Number of Nonfederal Psychiatric Hospitals

  •  491
  • Number of Nonfederal Long Term Care Hospitals

  • 140
  • Number of Hospital Units of Institutions 

  • (Prison Hospitals, College Infirmaries, Etc.)
    19
  • Total Staffed Beds in All U.S. Registered*Hospitals

  • 987,440
  • Staffed Beds in Community**Hospitals

  • 825,966
  • Total Admissions in All U.S.Registered* Hospitals

  • 35,644,440
  • Admissions in Community**Hospitals

  • 33,813,589
  • Total Expenses for All U.S.Registered* Hospitals

  • $426,849,488,000
  • Expenses for Community**Hospitals

  • $383,735,757,143
  • Number of Rural Community**Hospitals

  • 2,167
  • Number of Urban Community**Hospitals

  • 2,741
  • Number of Community Hospitals in a System***

  • 2,260
    Number of Community Hospitals in a Network****
    1,341
    *"Registered hospitals are those hospitals that meet AHA's criteria for registration as a hospital facility...
    **Community hospitals are defined as all nonfederal, short-term general, and other special hospitals....Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries
    ***System is defined by AHA as either a multihospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. ...System affiliation does not preclude network participation.
    ****Network is a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Network participation does not preclude system affiliation.

    All this table's Information is From the Mississippi Hospital Association

    The History , differences and Legal Definition of Non-profits and For-profits

    "The following paragraphs, and the table below it, are taken, annotated, and directly reliant on
    Health Policy Analysis Program Webiste [HPAP]. Community Benefits and Not For Profit Health Care, Policy Issues and Perspectives: November 1995. The Catholic Health Association. Madden, Katz et al
    The reader is strongly encouraged to access the source directly.
    "In the early days of the industry, most hospitals were small, not-for-profit organizations controlled by local communities or 
    religious orders with small budgets and big hearts. They stood ready to serve in times of medical or financial crisis, relying on philanthropy as well as patient fees for their support. For-profit hospitals were rare, concentrated in only a few regions of the country, 
    and frequently viewed with suspicion. Until recently , public policy in health care generally reflected consumers  preference for 
    not-for-profit organizations. [The strenth of this preference varied (and still varies) from state to state]...

    "The primary legal distinction between not-for-profits and proprietary organizations is that not-for-profits are prohibited from distributing earnings to owners. Not-for-profits can have owners, and can earn profits, but profits may not be dsitributed to owners in the form of annual dividends or other earnings-conditioned payments. This restriction is termed the non-distribution contraints.' ... 

    In a for-profit firm, the objective is very clear: maximize the return to owners. In addition,the owners are an easily identifiable and finite group of individuals. Important management decisions within such a structure can be made decisively, consistent with the course that maximizes returns. In a not-for-profit (particularly a community, rather than a religious) hospital, both ownership  and the interests of owners are less clear. Even the law is vague on issues of accountability and ownership in not-for-profits. Thus, important decisions 
    must balance the competing interests of many diverse parties who have varying degrees of unofficial power (e.g., physicians, 
    executive staff, board members, influential community members)...

    "Not-for-profits are more likely than  for-profits to provide high cost/low reimbursement services (e.g., neonatal intensive care, high  risk obstetrics, burn care, trauma centers, therapeutic radiology, HIV treatment) (Pattison and Katz, 1983; Shortell et al, 1986; Friedman et al, 1990; VHA, 1994).  Not-for-profits may also dominate the provision of innovative treatments....Clement et al (1990) found that not-for-profits offer more community-oriented services (many of which are money losers) than for-profits."

    "Not For Profit Hospitals: 
    Historically, not-for-profit health care oganizations-especially hospitals- have yielded important community benefits beyond the value of the health care they provide. They could provide these benefits because they were confident the costs would be covered by philanthropy, or by charging public or private payers higher prices. They could charge higher prices because their was no real competition....

    "As the industry developed, and as government's role increased, the economic environment facing hospitals changed. Growth in the number and size of hospitals reduced the need for general medical and emergency stand-by capacity in most settings since direct sales volume was sufficient to support services. The implementation of Medicare and Medicaid legislation in the mid-sixties gave government a prominent role in financing care to low income and elderly patients, reducing the need for not-for-profits to provide charity care and sufficient (in some cases, too much) stand-by capacity. By 1980, the flow of funds into the industry had increased dramatically, increasing the size and complexity of hospitals, and substantially altering the quasi-public role of the not-for-profit sector...

    "The primary legal distinction between not-for-profits and proprietary organizations is that not-for-profits are prohibited from distributing earnings to owners. Not-for-profits can have owners, and can earn profits, but profits may not be dsitributed to owners in the form of annual dividends or other earnings-conditioned payments. This restriction is termed "the non-distribution contraints.' An original rationale for this constraint is to keep earnings with the organization to preserve its assets or provide community benefits, a rationale which may or may not be recognized by current interpretations of law. In exchange for this promise, not for protfits are afforded ceratin tax and other advantages (some of which may be conditioned on the stated area  of activity of the organization). ....Key among the intangibles that consumers value are stand-by capacity, public goods, and trust. All three figure strongly in the historical dominance of not-for-profit institutions in health care markets...

    "For Profit Hospitals can distribute profits to owners in order to attract and retain capital ... The non-distribution constraint eliminates [for the non-profits] the possibility of raising investment funds in the usual fashion: by selling shares of ownership in well-established capital markets..... Since philanthropy decreased as government took on more of the charity care burden, not-for-profits were left with retained earnings and (frequently tax-subsidized) debt markets to raise investment capital....

    "Economic theory views the rationale for not-for -profits as a response to market failure (Weisbrod, 1977(2340; Hansmann, 1980 (96)). For profit firms operate successfully in markets where consumers willingness to pay for products and services is captured through direct sales of these items. In some markets, however, consumers want something less tangible than a can of soup or an automobile. Because these intangibles are hard (if not impossible) to measure, firms have a difficult time generating revenue through direct sales. ...

    "Today, competition is heating up. Proprietary companies are expanding in or entering new health care markets by purchasing or exclusively contracting with hospitals, managed care organizations and physicisian practices.   In response , not-for-profit hostpitals are seeking strategic alliances with other organizations, expanding product lines, integrating vertically, and cutting operating and administrative costs, often mimicking the aggressive actions of their for-profit competitors. And employers and state and federal governments are pushing hospitals to cut prices, making irt more and moredifficult to finance traditional community benefits.
    Many policy makers support these health care market changes, because they expect competition to control health care spending, promote efficiency and innovation , and improve the quality of  services. ......

    "Where once the voluntary hospital had been small, basic, and locally controlled, the not-for-profit of the 1980s was large and complex. And by the 1990s, it was more likely to be part of a large corporate system, often with distant ownership or control and strong contractual ties to managed care or other (sometimes for-profit) insurers.

    "The Rise of For-Profits
    "For Profit Hospitals can distribute profits to owners in order to attract and retain capital..For profit firms operate successfully in markets where consumers willingness to pay for products and services is captured through direct sales of these items. In some markets, however, consumers want something less tangible than a can of soup or an automobile. Because these intangibles are hard (if not impossible) to measure, firms have a difficult time generating revenue through direct sales..

    "Opportunities for growth were not restricted to the not-for-profit sector. Proprietary systems of hospitals developed and grew, extending their reach from a few markets in the southeast to an increasing presence nationwide. The rise of the for-profit hospital relates both to the diminished public good role of not-for-profits and to the primary disadvantages of the non-distribution constraint: the inability to raise capital quickly, and the diffuseness of control brought about by the absence of clear property rights.......

    "Property Rights
    In a for-profit firm, the objective is very clear: maximize the return to owners. In addition,the owners are an easily identifiable and finite group of individuals. Important management decisions within such a structure can be made decisively, consistent with the course that maximizes returns. In a not-for-profit (particularly a community, rather than a religious) hospital, both ownership and the interests of owners are less clear. Even the law is vague on issues of accountability and ownership in not-for-profits. Thus, important decisions must balance the competing interests of many diverse parties who have varying degrees of unofficial power (e.g., physicians, executive staff, board members, influential community members). Such a balancing act is a time-consuming endeavor in which maximizing return on assets rarely dominates and which often frustrates decisive management decisions so essential in a competitive environment......

    "Where once the voluntary hospital had been small, basic, and locally controlled, the not-for-profit of the 1980s was large and complex. And by the 1990s, it was more likely to be part of a large corporate system, often with distant ownership or control and strong contractual ties to managed care or other (sometimes for-profit) insurers.

    "For-profits and not-for-profits now scramble side by side for market share, often using similar competitive strategies. In addition, both types of providers are facing new payment schemes that have raised questions in consumers' minds about whose interests are being serviced....This apparent conflict erodes trust in provider organizations, regardless of ownership.

    "Thus, the differences between not-for-profits and for-profits are beginning to fade in the eyes of consumers, and trust proxies of the past are breaking down.  But while the value of old trust proxies is decreasing, the demand for trust is not. .....Some of the larger for-profit chains are working hard at generating new measures of trust which include them, but for the moment, the market for trust is in chaos....

    "Not-for-profits are more likely than  for-profits to provide high cost/low reimbursement services (e.g., neonatal intensive care, high  risk obstetrics, burn care, trauma centers, therapeutic radiology, HIV treatment) (Pattison and Katz, 1983; Shortell et al, 1986; Friedman et al, 1990; VHA, 1994).  Not-for-profits may also dominate the provision of innovative treatments....Clement et al (1990) found that not-for-profits offer more community-oriented services (many of which are money losers) than for-profits."

    The Information in the Above Table is  taken, annotated, and directly reliant on
    Health Policy Analysis Program Webiste [HPAP]. Community Benefits and Not For Profit Health Care, Policy Issues and Perspectives: November 1995. The Catholic Health Association. Madden, Katz et al
    The reader is strongly encouraged to access the source directly

     


    The Statistics on Service relevant to non-profit vs for-profit
     



    Sources beyond those given directly in Text and provided with footnote numbering are:

    1. FOR-PROFIT CONVERSIONS OF NONPROFIT HOSPITALS AND HEALTH PLANS -- 1997. Part of State Legislative Trends and Analysis. Special Report to the 1997 House of Delegates. Submitted by the Department of State Government Relations and the Department of Political and Grassroots Programs

    2. Information from AmericanHospitals.com