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Guide to Hospitals: Advice & Explanations Search Again Search Hospitals

 

Introduction

Few of us look forward enthusiastically to a stay in a hospital. That's as it should be. Hospital stays are not fun, and stays at even the very best hospitals pose significant risks of infections and other mishaps.

But you'll be more comfortable entering a hospital if you know that the hospital stay is really necessary, that the hospital was selected carefully, and that you know how to deal effectively with the hospital's staff. This guide is intended to help you find that peace of mind.

For each of over 4,800 acute-care hospitals nationwide, this guide gives you important information on what has actually happened to each hospital's patients: estimates of the percent of patients with various types of cases who have died or experienced adverse outcomes, including complications.

For hospitals in major metropolitan areas, we give you results from a major survey we conducted, in which we gathered more than 140,000 ratings of hospitals from physicians in those areas: we tell you how each hospital was judged by those physicians.

Where data are available, we also give you ratings from patients who have used the hospitals, results from studies of data that examined how often hospitals performed the proper tests and procedures for common cases, and other key facts that relate to quality.

Whatever hospital you choose, you'll want to get the best care the hospital has to offer. What you get depends in part on how well you are informed about what to expect during your stay—why you are there, what drugs and procedures you're to be exposed to, how much attention you should get from the nursing staff, etc. It also depends on how carefully you and your family and friends keep an eye on what the staff is doing. This guide will help you prepare for your stay and play a useful role in your care.

Finally, you'll find advice on ways to help keep down the cost of your hospital stay. That's good for you and good for the community.


Learning About Your Case

You must learn as much about your case as time allows. This education is also essential for you to answer two other critical questions: what is really wrong with you and what is the best approach to treatment? In addition, whatever you learn will help you play an active role later on in monitoring your care

If a doctor recommends hospitalization, here are a few questions for you to ask (often in this guide when we refer to "you," we assume it is relatives or friends who will take responsibility for a sick patient):

  • What is the basis for the diagnosis? Are there other possible explanations for your symptoms? Might it make sense to do further tests or simply to wait awhile to get a surer diagnosis?
  • What are the alternative ways of treating your problem? What are the pros and cons of each—the chances of various outcomes in terms of your lifestyle and ability to function?
  • Can your problem be treated outside of a hospital? If there are outpatient options, what are their pros and cons?
  • Why are the particular hospital, and the particular doctor who would care for you, good choices for your care?
  • How complicated is the treatment you will get? Does it require sophisticated medical staff or advanced equipment?
  • What are the risks of complications? Will it be important to have close monitoring and quick access to sophisticated medical staff and equipment at all times?
  • Is your required treatment one for which special training or frequent experience is important? Are there certain hospitals or specialists who have more skill, more experience, and higher success rates than others with this treatment?

Up-to-date physicians will encourage you to ask such questions, will offer answers, and will steer you to sources for further research. Don't be concerned about insulting your physician by asking questions. It helps to write out your questions as a reminder. If your doctor is hard to talk with, take along a friend to help you press for answers.

A good physician will also encourage you to seek a second opinion. Get one.

Get your second opinion from an entirely independent doctor. If a surgeon who has recommended surgery refers you to another surgeon for a second opinion, it will be difficult for the second doctor to recommend against the advice (and the economic interests) of the first. To find a doctor to use for a second opinion, you can ask friends and co-workers for recommendations, contact a medical school, or ask for a referral from a well-regarded hospital. To help you find a knowledgeable physician, our www.guidetotopdoctors.org identifies more than 24,000 top physician specialists who were most often recommended by their peers in surveys we sent to nearly all the office-based physicians practicing in major metropolitan areas. These physicians should be excellent prospects for seeking a second opinion. If you read up on your type of case—especially if it is of a type that is being actively researched at certain medical centers—you may come upon names of leading specialists who might be available for advice. When two doctors from whom you get opinions disagree or are uncertain, you may want to seek additional opinions.

To keep down the cost and time required for a second opinion, have your first doctor send copies of your medical records, x-rays, and lab results to the second opinion doctor. This is standard procedure.

Medicare and most insurance plans will pay for second opinions, and in some circumstances plans may pay for third opinions. In some types of cases, insurance plans require second opinions.

Don't assume that because yours is a straightforward, uncomplicated case there is nothing to learn and there are no decisions to be made. In most cases, there are choices.

This point is brought home by studies done by Dartmouth Medical School researchers and others, looking at variations in medical practice in common types of cases across similar geographic areas. Some of the early studies found, for example, that about 75 percent of the elderly men in one Maine town had undergone prostate surgery, compared with fewer than 25 percent of men the same age in an adjacent town. Similar variations were found in rates of hysterectomies, caesarean sections, and other common procedures. Significantly, studies generally find no evidence that such medical practice differences result in differences in the health status of the affected populations.

The implication is that big differences in the ways patients are treated result from differences in the beliefs and customs of different physicians in different communities—possibly influenced by financial considerations—the need to generate fees—and not necessarily based on sound evidence of likely benefits to the patient. Even in a common type of case, you can't assume that a physician's recommendation is the best option for you.

Also, for many types of conditions, there are different treatment options with different likelihoods of health improvement, discomfort, harm to the patient, and even death; only you, when fully informed, can decide which kinds of risks and benefits you weigh most heavily.

To learn about your case, you can use various online resources. You can find some valuable ones at www.checkbook.org/health/disease-treat.cfm. You can also check one or more family health books. Examples are the Harvard Medical School Family Health Guide, the Mayo Clinic Family Health Book, The Merck Manual of Medical Information, and the American College of Physicians Complete Home Medical Guide.

For more information, you can take advantage of libraries. At public libraries, you can look at consumer-oriented newsletters and at medical textbooks. For more in-depth information, you can use a medical school library. These libraries will have both general textbooks and texts in specialty fields. They will also have peer-reviewed medical journals, which will have articles on new developments not yet reflected in textbooks.

There are some websites that are specifically oriented toward not only informing but also fostering patient decision-making. Ottawa Hospital Research Institute's Patient Decision Aids is a catalog of links to decision guides, on topics ranging from "Should I have surgery for my torn meniscus?" to "Should I have surgery to cure ulcerative colitis?" The website http://www.healthtalkonline.org has videos of patients telling about their choices and experiences with conditions ranging from cervical cancer to heart failure.

A source of valuable insight on hospital risks and how to minimize them is Consumer Reports' website www.safepatientproject.org.

As you learn more about your treatment choices, you'll also learn about hospital choices. If yours is a case that requires a high degree of specialization that is currently available only at a few medical centers, you will want to use one of these centers for treatment. If yours is a complicated, high-risk case, you will want to use a hospital with sophisticated capabilities to deal with complications. If your case is low-risk, you might choose to give substantial consideration to the pleasantness of the staff and facility and its convenience to your home, family, and friends.


Why Your Choice of Hospital Matters

Today's hospitals can shatter kidney stones with sound waves; look at tissues deep inside a patient's body without ever making a cut; have machines to take over when organs fail; in short, do what only a few decades ago was beyond belief.

But hospitals remain today, as they always have been, dangerous places. Where else do you allow someone to cut deep into your body, inject potent chemicals into your veins, feed you strong drugs, and intervene in your life in so many other ways? In the operation of such powerful forces, at a time when you are sick and vulnerable, a single mistake can have catastrophic consequences.

And mistakes do occur: missed diagnoses as a result of inaccurate lab or x-ray results, administration of unprescribed medication, too slow response in emergencies, infections passed among patients, heart attacks caused by feeding the wrong solution into an IV hookup, operations on the wrong patient or the wrong organ, unintended lacerations of healthy organs, patients falling down or falling out of bed while under sedation, chokings from vomiting of meals improperly given before surgery, and many more.

In fact, authoritative studies have concluded that more than 40,000 patients per year, and possibly more than 90,000 per year, are killed in hospitals by preventable medical errors. That is more than the number of deaths attributable each year to motor vehicle accidents, breast cancer, or AIDS. And there are also many thousands of other cases where hospital or physician negligence, while not causing death, slows recovery or leads to short-term or long-term disability.

And those are the cases of negligence. There are countless cases where doctors and hospitals are not negligent but do fail to provide the best possible care—the kind of innovative, skilled, responsive care that might give you better than average chances of a successful and speedy cure or recovery.

A speech given years ago by Donald M. Berwick, a well-known physician, Harvard Medical School professor, and chief executive of the Institute for Healthcare Improvement, put a human face on problems that have persisted through the years. He described—with his wife, Ann's, permission—the experience he and Ann had endured during a year in which Ann had six hospitalizations for a total of over 60 inpatient days in three institutions:

"Let me first say that this painful summer and fall has left me more impressed than I have ever been before with the good will, kindness, generosity, commitment, and dignity of the people who work in health care—almost all of them...

"Which makes it hard to tell the other side of the story. Put very, very simply: the people work well by and large, but the system often does not...

"[Medication errors] were not rare, they were the norm. The neurologist in one admission told us in the morning, 'by no means should you be getting anticholinergic agents,' and a medication with profound anticholinergic side effects was given that afternoon. The attending neurologist in another admission told us by phone that a crucial and potentially toxic drug should be begun immediately. He said, 'time is of the essence.' That was on Thursday morning at 10:00 a.m. The first dose was given 60 hours later... Colace was discontinued by a physician's order on Day 1, and was nonetheless brought by the nurse every single evening throughout a 14-day admission...

"A spinal tap was done for a crucial test for Lyme disease, but the doctor collected too little fluid for the test, and the tap had to be repeated. During a crucial phase of diagnosis, one doctor told us to hope that the diagnosis would be of a certain disease, because that disease has a benign course. The same evening, another doctor told us to hope for the opposite, because that same disease is relentless—sometimes fatal... [Information was] collected in disorganized, narrative formats, embedded in nursing notes and daily forms... As a result, physicians often reached erroneous conclusions about the past...

"On at least three occasions, Ann waited alone for over an hour, cold, and frightened on a Gurney in the waiting area outside an MRI unit in a sub-basement in the middle of the night... Ann's bedtime was 10:00 p.m., but her sleeping medication was often brought at 8:00 p.m. to accommodate changes in nursing shifts... One place gave a sleeping pill at 3:00 a.m., and then routinely woke Ann at 4:00 a.m. to take her blood pressure, which never varied from normal."

These were just some of the examples Berwick reported. Fortunately, by the time he delivered the speech, he could report that Ann's condition had clearly begun to improve. But he and Ann, among the most sophisticated of all possible patients, much more able than most to recognize problems, had seen both the best and the worst of hospital care. Berwick has used his and his wife's personal story as part of his life's work—to exhort his professional colleagues to make the system work better. The rest of us can take from it a warning that we must be vigilant in the selection of hospitals for care, and we must be vigilant and actively involved in our care in whatever hospital we use.

What you want for your care is a hospital that will keep mistakes to a minimum and that will help you quickly improve your medical condition and your ability to function; limit your discomfort; improve, or at least maintain, your morale; and make your stay reasonably pleasant.

One of Berwick's conclusions about the hospitals in which his wife received care was that "some were, in fact, much better than others." That is a conclusion supported by the data in this guide and by much other research. There are differences in how astute medical staffs are at spotting changes in a patient's condition, how adept nursing staffs are at instilling optimism in their patients, how good a facility's entire staff is at maintaining sanitary conditions, and myriad other aspects of hospital performance.

Certainly, if you are among the roughly one out of 10 Americans who will be admitted to a hospital this year, you will want to be sure it's one of the best. But judging hospital quality is complex. Differences in hospitals' death rates among heart attack patients, for example, might simply mean that some hospitals get sicker, more frail patients; or that some send their patients prematurely to nursing homes, where they die; or that some are used by a few incompetent physicians who lose their patients despite the best possible care from the hospitals' own staffs.

In this guide, we advise you on some facts to look for in selecting a hospital and we suggest ways you can enhance the quality of care you receive at whichever hospital you choose. The guide includes extensive information on individual hospitals to help you choose a good one. We report data on death rates and rates of other adverse outcomes, results of surveys in which thousands of physicians rated hospitals, results of studies that looked at whether or not hospitals performed the proper tests and procedures for common cases, how hospitals were rated by their own patients, and other facts.

Unfortunately, these data do not give a clear-cut way to sort the best hospitals from the worst. All of the measures have some methodological shortcomings, which are discussed at some length under Choosing the Best Hospital. Some hospitals look good on some measures and not on others. But this information will enable you to find a few hospitals that look good across the board, and will add to what you know about almost any hospital you might consider. The information will help you have informed discussions about hospital choice with your physician.

By making the data in this guide accessible to consumers, we hope we have strengthened incentives for government, the hospital industry, and health care researchers to continue to make improvements in methods for comparing hospitals.


The Need to Choose

Much of the responsibility for choosing the right hospital for you rests with your doctor. But you too must play an important role.

Your choice of hospital will generally be rather narrow if your primary care doctor proposes admitting you to a hospital under his or her own care. Most doctors have arranged privileges for themselves to admit patients only at a few hospitals, or a single hospital.

But there's a good chance your primary care doctor will refer you to a specialist who will be the one who arranges for your admission to a hospital. You can consider hospital affiliation as one basis for selecting the specialist you will use.

Your primary care doctor will probably favor a specialist who practices at one of his or her own hospitals. These are usually the specialists your doctor knows best. Also, your doctor may want to see you in the hospital and work with the specialist. But the choices need not be limited to your doctor's hospitals. You will want your primary care doctor to remain involved in your case, to advise you and assure that all aspects of your care are coordinated, but the doctor might not have to have privileges at the hospital where you will be admitted in order to play this role. Discuss this issue with your primary care doctor. Ask your doctor if he or she can arrange to keep up-to-date on your care by communicating with the doctor or doctors who will be responsible for you in the hospital.

All this presumes that you have a primary care doctor. But there is another point at which comparison of hospitals is important: when you are first choosing a doctor or health plan. There are two reasons to look for a doctor or health plan that uses high-quality hospitals. First, this will enhance your chances of being admitted to such a hospital in the future if the need arises. Second, it enhances your chances that your doctor will be a top-quality professional: good hospitals can be expected to attract good physicians.

A comparison of hospitals is especially important if you are considering a health maintenance organization (HMO) or a preferred provider organization (PPO). If an HMO or PPO uses high-quality hospitals, that suggests its overall medical care standards are high.


Choosing the Best Hospital

Given the importance of choosing a high-quality hospital, much of this guide is devoted to helping you make a good selection. There will be no clear-cut answers, but we give you key information to help you judge most of the hospitals in the U.S., and we advise on additional information you can collect on your own.

Below is an overview, with a brief description of the information this guide provides you on individual hospitals, additional information you can gather on your own, and how you can use the information to make a hospital choice. The section More About Our Data is a more detailed description of our data on individual hospitals and the strengths and weaknesses of these data.


Overview of the Data and Ratings Tables

We include in our Ratings Tables nearly every short-term hospital for acute inpatient care in the U.S. except Veterans and military hospitals. Below, we briefly describe the data in our tables.

Summary

  • Percent of Doctors Who Rated the Hospital High. These are the percentages of physicians who, in a large survey we conducted, rated each hospital "very good" or "excellent" for "surgery on an adult in cases where the risk of complications is high." We also show the number of doctors who rated each hospital on this question.
  • Risk-Adjusted Death Rates for All Selected Cases.These are the percentages of each hospital's patients, for a three-year period, who died within 30 days of the time they were admitted to the hospital. These rates are adjusted—to the extent we were able—for differences in how sick and frail each hospital's patients were. Rates are reported for selected, relatively high-risk cases in three categories: medical cases, surgical cases, and a combination of medical and surgical cases. We also show the number of cases that were examined for each hospital for the analysis. This analysis is based on data for Medicare patients.
  • How Often the Hospital Did Proper Tests and Treatments (Best Practices) for Selected Cases. These are the percentages of instances in which each hospital gave the test or treatment that would be called for by evidence-based guidelines—for example, gave heart-attack patients aspirin upon arrival or gave proper antibiotics to prevent surgical infections. The score shown is an aggregate score calculated across four different types of care: heart attack, heart failure, pneumonia, and surgical infection prevention. We also show the number of observations in which each hospital's performance—either doing what was called for or not—was checked. This analysis is based on data collected by the federal government for its Hospital Compare website.
  • Percent of Patients Who Would Recommend the Hospital. These are the percentages of patients who, in federally sponsored surveys of hospital patients, said they "would definitely recommend" the hospital they had recently used.
  • For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition, we give our checkmark () to hospitals that rated high on an overall score we calculated across a range of measures.

Doctors' Ratings/Recommendations

  • Ratings for High-Risk Adult Surgery. These are the percentages of physicians who, in a large survey we conducted, rated each hospital "very good" or "excellent" for "surgery on an adult in cases where the risk of complications is high." We also show the number of doctors who rated each hospital on this question.
  • Desirability scores from doctors. These are the results when we asked each surveyed physician to name the two hospitals, from a list in the physician's metropolitan area, that he or she would consider "most desirable" and the two he or she would consider "least desirable" for several different types of health care needs, from "uncomplicated delivery of a baby" to "medical care for an adult in complex cases." We report for each hospital for each type of case the percentage of its mentions that were favorable: that is, the number of times physicians mentioned it as desirable as a percentage of the total times physicians mentioned it as either desirable or undesirable.
  • For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition, we give our checkmark () to hospitals that rated high on an overall score we calculated across a range of measures.

Death & Adverse-Outcome Rates—Overall

  • Risk-Adjusted Death Rates for All Selected Cases.These are the percentages of each hospital's patients, for a three-year period, who died within 30 days of the time they were admitted to the hospital. These rates are adjusted—to the extent we were able—for differences in how sick and frail each hospital's patients were. Rates are reported for selected, relatively high-risk cases in three categories: medical cases, surgical cases, and a combination of medical and surgical cases. We also show the number of cases that were examined for each hospital for the analysis.
  • Risk-Adjusted Death Rates for All Medical Cases. These percentages show overall risk-adjusted death rates for the medical cases we examined for our death-rate analysis. We also report the number of cases that were examined for each hospital.
  • Risk-Adjusted Death Rates for All Surgical Cases. These percentages show overall risk-adjusted death rates for the surgical cases we examined for our death-rate analysis. We also report the number of cases that were examined for each hospital.
  • Risk-Adjusted Adverse-Outcome Rates for All Selected Surgical Cases. These are similar to the death rates except that adverse outcomes include both deaths and complications (estimated by us) that resulted in extended stays in the hospital.
  • For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition, we give our checkmark () to hospitals that rated high on an overall score we calculated across a range of measures.

Death and Adverse-Outcome Rates for Specific Medical and Surgical Cases

  • These tables show, for specific types of cases, whether or not the hospital's death and adverse-outcomes rates were "Better" or "Worse" than would be expected, given how sick and frail its patients were. To get a "Better" or  "Worse," a hospital had to do enough better (or worse) than expected that we could be quite confident that its better (or worse) performance was not just a matter of luck. Where we list "Average" for hospitals, it simply means that we could not be confident that their outcomes were different from what would be expected, given how sick and frail their patients were. There are also many hospitals that have "Insufficient data" on the tables for many categories of cases. That means these hospitals had a relatively small number of cases in these categories—so small that we could not make a judgment on their outcomes.

How Often the Hospital Did Proper Tests and Treatments (Best Practices) for Selected Cases

  • These are the percentages of instances in which each hospital gave the test or treatment that would be called for by evidence-based guidelines—for example, gave heart-attack patients aspirin upon arrival or gave proper antibiotics to prevent surgical infections. The score shown is an aggregate score calculated across four different types of care: heart attack, heart failure, pneumonia, and surgical infection prevention. We also show the number of observations in which each hospital's performance—either doing what was called for or not—was checked.

  • Heart Attack. Shows the percent of times the hospital performed the proper tests and procedures for heart attack patients and the number of observations.
  • Heart Failure. Shows the percent of times the hospital performed the proper tests and procedures for heart failure patients and the number of observations.
  • Pneumonia. Shows the percent of times the hospital performed the proper tests and procedures for pneumonia patients and the number of observations.
  • Surgical Infection Prevention. Shows the percent of times the hospital performed the proper tests and procedures for preventing surgical infections and the number of observations.
  • For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition, we give our checkmark () to hospitals that rated high on an overall score we calculated across a range of measures.

Ratings from Patients

These ratings come from federally sponsored surveys of patients who had had recent hospital stays.

  • Patients Would Recommend Hospital. The percentage of patients who said they "would definitely recommend" the hospital they had recently used.
  • Overall Rating. Percent of patients who gave hospital an overall rating of 9 or 10 (on a 0 to 10 scale).
  • Communication with Doctors. Percent of patients who reported doctors at hospital "always" communicated well.
  • Communication with Nurses. Percent of patients who reported nurses at hospital "always" communicated well.
  • Receiving Help Quickly. Percent of patients who reported they "always" received help as quickly as they wanted it.
  • Medicines Always Explained. Percent of patients who reported that hospital staff "always" explained about medicines before giving them.
  • Pain Was Well Controlled. Percent of patients who reported that their pain was "always" well controlled.
  • Rooms Were Quiet. Percent of patients who reported that the area around their room was "always" quiet at night.
  • Rooms Were Clean. Percent of patients who reported that their room and bathroom were "always" clean.
  • Given Information About Recovery at Home. Percent of patients who reported that they were given information about what to do during their recovery at home.
  • For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition, we give our checkmark () to hospitals that rated high on an overall score we calculated across a range of measures.

Other Useful Information & Notes

  • Major Medical School Affiliation. This is simply one indicator of the extent of each hospital's teaching programs for doctors.
  • Leapfrog Hospital Safety Score. These data come from The Leapfrog Group, an organization that tracks and encourages hospitals' efforts to improve patient safety. The Hospital Safety Score is an A, B, C, D, or F letter grade reflecting how safe hospitals are for patients. Scores are based on Leapfrog's analysis of hospital safety performance in dozens of areas, including results from Leapfrog's own surveys of hospitals.
  • Notes. To view available notes for individual hospitals, see the footnotes at the bottom of the table.

  • More About Our Data

    The following is a more detailed discussion of the data and how they should be interpreted.

    Physician Ratings

    To collect physicians' ratings of hospitals, we mailed questionnaires to about 340,000 physicians in the 53 largest metropolitan areas of the U.S. and received more than 20,000 responses. We surveyed virtually all of the actively practicing, office-based physicians in these areas. For most metropolitan areas, our survey was conducted during the spring and summer of 2008, but for some areas—the Boston, Chicago, Philadelphia, San Francisco, Seattle, Twin Cities, and Washington, DC, areas—our survey was conducted in 2010.

    We gave each physician a list of area hospitals and asked the physician to rate each "for surgery on an adult in cases where the risk of complications is high." The physicians were asked to use a five-point scale: "excellent," "very good," "good," "fair," or "poor," and simply to leave the form blank for hospitals for which they couldn't answer.

    Our Ratings Tables show for each hospital the percentage, among the physicians who rated it, who said it was either "very good" or "excellent." The tables also shows the number of raters for each hospital. We have not reported data on any hospital rated by fewer than 20 physicians. Some hospitals were rated "very good" or "excellent" by more than 70 percent of the physicians who rated them, while some got such favorable ratings from fewer than 10 percent. We use green type to denote the most favorable scores and red type to denote the least favorable scores.

    We believe these ratings are a useful indicator of hospital quality, but you should keep several caveats in mind—

    • In some cases, physicians may not have had a good basis for judging hospitals. A physician who regularly visits a hospital can get a good perspective on how responsive and thorough the nurses and other staff are, how clean and organized the facility is, and other aspects of quality. But most physicians don't see all parts of a hospital or see how it performs with all types of cases. And many of the ratings were likely based on reputations among the physicians' peers rather than direct experience.
    • Physicians may have had biases—and possibly financial and professional interests based on their hospital affiliations—that influenced their ratings of specific hospitals.
    • The types of physicians who responded to our survey might have had different opinions of the hospitals than the types who chose not to respond.
    • Even if there was no consistent difference between the types of physicians who responded and the types who did not, we know that for each hospital there is a mix of opinions among physicians, and it is possible that some hospitals got relatively low (or high) scores simply because they had bad (or good) luck in who happened to respond. For example, for one hospital, our survey might have reached a few physicians with the most negative opinions on a day when these physicians had time to respond while physicians who would have given negative ratings of another hospital were too busy to respond on the day the survey reached them. Naturally, such bad or good luck is less likely to be the explanation for one hospital's being rated higher than another if the number of raters was large or the two hospitals' scores are very different.

    We also asked the physicians to tell us which two hospitals in the area were most desirable and which were least desirable for various types of cases—

    • Surgery on an adult in cases where the risk of complications is high
    • Surgery on an adult in cases where the risk of complications is low
    • Medical care for an adult in complex cases
    • Surgery on a child in cases where the risk of complications is high
    • High-risk delivery of a baby
    • Uncomplicated delivery of a baby

    For each type of case, we counted the total number of times each hospital was mentioned favorably and compared that number to the total number of times it was mentioned at all (either favorably or unfavorably). The Ratings Tables show, for each hospital for the types of cases listed, the percentage of mentions that were favorable. For example, if a hospital was mentioned for a given type of case as most desirable by eight doctors and as least desirable by two doctors, that would give it a score of 80 (eight favorable mentions divided by 10 total mentions equals 80 percent). On the Ratings Tables, we have not reported scores for a type of case for any hospital that was mentioned fewer than six times, and we have marked with an asterisk (*) any score that is based on fewer than 10 mentions.

    This most desirable/least desirable approach to scoring doesn't allow formal assessments of the statistical significance of hospital-to-hospital differences. But hospitals that look good based on the most desirable/least desirable approach tend also to look good when rated on the five-point poor-to-excellent scale. Since we used both types of questions to ask about "adult surgery in cases where the risk of complications is high," we can compare the results. Consider, for instance, hospitals that received at least 10 most desirable/least desirable mentions and at least 25 ratings on the poor-to-excellent scale; of those that scored in the top half based on most desirable/least desirable mentions, 92 percent were also in the top half based on their score on the poor-to-excellent scale.

    You can, on a smaller scale, collect the same kind of information that we collected from physicians. You can ask physicians you know for their recommendations, and you can ask your friends to get the thoughts of physicians they know.

    Death Rates

    In choosing a hospital, you will want to know how successful the facilities you are considering have been in delivering good results for other patients. The most important result is keeping patients alive.

    On our Ratings Tables, we report risk-adjusted death rates. These rates were adjusted in an effort to take into account the fact that some hospitals treat a relatively high percentage of sicker and frailer patients, who would have a relatively high risk of dying at any hospital.

    The adjusted death rates are based on analysis of records of hospital stays of Medicare patients 65 or older admitted to hospitals in two Federal Fiscal Years, from October 1, 2008, through September 30, 2010—over 25 million hospital admissions nationwide. This is the only available uniform, nationwide data file of hospital cases.

    The hospitals submit records to Medicare to get reimbursed for services rendered. Medicare adds one fact to the records submitted by the hospitals—whether the patient died within a specified number of days after hospital admission. Medicare gets this information on deaths, even on deaths that occurred after a patient's discharge from the hospital, by using Social Security records.

    Our mortality rate analysis was conducted by Michael Pine and Associates, a Chicago-based firm that is expert in evaluating the clinical quality of hospitals.

    The analysis began with the selection of a subset of cases. We selected types of cases that are relatively common and that have substantial death rates that might be affected by the quality of a hospital's care. The cases included acute myocardial infarction (heart attack), obstructive pulmonary disease, cerebrovascular accident (stroke), and seven other types of cases in which patients were treated medically. They also included 11 types of surgical cases, such as coronary artery bypass graft surgery, large bowel surgery, and total hip replacement. The cases were selected from the Medicare records based on detailed definitions using standard diagnosis and procedure codes.

    On the Ratings Tables, you will see, for example, a column showing "risk-adjusted death rate for all selected cases." You will see that the death rates range from below nine percent to more than 13 percent. This difference suggests that, among similar patients with serious medical problems or surgical procedures, those going into one of the high-death-rate hospitals have a four-percentage-point higher chance of dying than those going into one of the low-death-rate hospitals.

    A four-percentage-point difference in chance of dying in a few days is something that most people will be intently interested in avoiding. To put this figure in perspective, consider a four-percentage-point difference in death rates for a few days of stay in two different hotels—one hotel with a zero-percent death rate and the other with a four-percent death rate among visitors staying there for a few days. Such a difference would certainly be headline news.

    It is important to note that we did not look at all cases. The average death rate across all hospitals for all the types of Medicare cases we selected is higher than the death rate would be if we reported on all cases, including low-risk cases, the hospitals treated. So hospitals are not as dangerous overall as the death rates for our selected cases might suggest, but the adjusted death rates we present are useful in comparing the hospitals for a broad group of serious types of cases.

    Adjusted death rates were calculated in several steps.

    First, for each type of case, we calculated the actual death rate for each hospital. We counted all deaths that occurred within 30 days of admission, even if they occurred after the patient was discharged from the hospital. Checking for this 30-day period eliminates the possibility that a hospital might have relatively low death rates only because it discharges patients to their homes, hospice care, or nursing homes when they are on the verge of death.

    We then calculated a "predicted" death rate for each type of case for each hospital. The predicted death rate tells what percent of the hospital's patients would have died if the hospital were just as successful as the average of all U.S. hospitals in keeping similar patients alive. The patient characteristics that were taken into account in determining whether patients were similar were age, gender, the presence or absence of selected principal and secondary diagnoses, and whether certain surgical procedures were performed. For example, a hospital that had heart attack patients who were mostly over age 85 with secondary diagnoses like congestive heart failure, diabetes, and malnutrition, might have a considerably higher predicted death rate for heart attack cases than a hospital whose heart attack patients were mostly age 65 to 70 and had few other medical problems. (More detail on the methods used by Michael Pine and Associates to calculate predicted death and adverse outcome rates is included in the technical report.)

    Next, we used each hospital's predicted death rate and actual death rate along with the national-average death rate to calculate an "adjusted" death rate for the hospital. The simplest way to calculate an adjusted rate is in two steps. First, we can calculate the ratio of the actual rate to the predicted rate. If, for example, Hospital A has an actual death rate of five percent but would be predicted to have a death rate of 10 percent based on how sick and frail its patients are, then the ratio is 0.5 (five percent divided by 10 percent). Second, we can multiply this ratio by the national average death rate to get the adjusted death rate. If the national average death rate were 12 percent, then the adjusted death rate for Hospital A would be six percent (12 percent multiplied by the 0.5 ratio). In fact, we used a more complicated formula (using odds ratios) for calculating adjusted rates, but the result is very nearly the same.

    For each hospital for each category of cases, we also checked whether the difference between the actual death rate and the predicted death rate was "statistically significant." For example, if the actual rate was nine percent and the predicted death rate was 10 percent, what are the chances that the one-percentage-point difference was the result of the hospital's simply having had unusually good luck with its patients during the four-year period we analyzed?

    We know that some patients survive when the average patient in a similar condition who experienced the same treatment would be expected to die, and some die when the average similar patient given the same treatment would be expected to survive. Since the difference in result can't be explained, we call it good luck or bad luck. And any given hospital might have a string of good luck or bad luck with its patients. But big differences between actual and predicted death rates for large numbers of cases are not likely to be the result of luck alone. For each hospital for each category of cases on the Ratings Tables, we have used different typefaces for the adjusted death rate to indicate whether the difference between the hospital's actual death rate and its predicted death rate was "statistically significant":

    • Green type—The hospital did better than predicted, and there's less than one chance in 40 that this better-than-predicted experience is just the result of good luck.
    • Regular type—although the hospital may have done better or worse than predicted, there's at least one chance in 20 that its better- or worse-than-predicted experience is just the result of good or bad luck.
    • Red type—The hospital did worse than predicted, and there's less than one chance in 40 that this worse-than-predicted experience is just the result of bad luck.

    On the "Death & Adverse Outcome Rates-Overall" tab of the Ratings Tables, we show adjusted death rates and statistical significance for two categories of cases: all selected case types (medical and surgical combined) and all selected medical cases.

    On the Ratings Tables under the "Death and Adverse-Outcome Rates for Specific Medical and Surgical Cases" tab of the Ratings Tables, we present death analysis results on those three categories of cases and also on more specific categories of medical cases, such as heart attack, stroke, and pneumonia. For specific surgical cases, we present adjusted adverse outcomes rates instead of death rates. (See below for a discussion of adverse outcomes rates.) These tables present the data differently from how they are presented for the "Overall" tables. Instead of reporting adjusted death rates, we simply indicate whether the hospital's death rate for each category of cases was statistically significantly better or worse than predicted, given the hospital's mix of patients. We score the hospitals as follows:

    • Better—the hospital did better than predicted, and there's less than one chance in 40 that this better-than-predicted experience is just the result of good luck.
    • Average—although the hospital may have done better or worse than predicted, it's likely that its better- or worse-than-predicted experience is the result of good or bad luck
    • Worse—the hospital did worse than predicted, and there's less than one chance in 40 that this worse-than-predicted experience is just the result of bad luck.

    If a hospital's number of cases or predicted number of deaths was too small, we reported neither adjusted death rates nor the significance of the difference between actual and predicted death rates. For such hospitals, the tables show "Insufficient data."

    Interpreting the Death Rate Data

    Let's look a little more fully at the strengths and weaknesses of the death rate data. How valuable are they in choosing a hospital for your care?

    The data are helpful in predicting a hospital's outcomes—especially among hospitals with a reasonably large number of cases. We have found over the years that hospitals that have significantly better-than-average adjusted death rates in one period are substantially more likely than other hospitals to have significantly better-than-average death rates in subsequent years.

    But, while the data have predictive power, there is much debate about the usefulness of such data for comparing hospitals. The following are some limitations that are important to keep in mind when considering the data on different hospitals—

    • From the billing records submitted to Medicare by the hospitals and used for our analysis, one cannot always be sure whether secondary diagnoses existed when the patient entered the hospital or whether they occurred during the hospital stay. Consider heart attack cases. If the patient's record says the patient had diabetes as a secondary diagnosis, we can be confident that the diabetes was there on admission. In contrast, if the record says the patient had pneumonia, we can't confidently make an assumption as to whether the patient came into the hospital with the pneumonia or acquired it in the hospital. Without knowing this, we can't know whether to give the hospital credit for having more difficult cases if it has an unusually large number of heart attack cases with pneumonia. We wouldn't want to give the hospital such credit in our analysis if the hospital is causing the pneumonia. Fortunately, Medicare since October 2008 (after much urging by Michael Pine and Associates and others) has been requiring hospitals to have a flag for each secondary diagnosis indicating whether it was present upon admission to the hospital. So, in our analysis, we could use that flag in a heart attack case with a secondary diagnosis of pneumonia to decide whether to give the hospital credit for having a patient who was relatively sick on admission as opposed to having had the pneumonia occur in the hospital.

      The presence of these flags has improved the validity of our analysis. But we know that the hospitals do not always apply the flags accurately-and that a hospital may have incentives to code secondary diagnoses as being present on admission since that will make the hospital's adjusted results look better than they otherwise would. So this aspect of our analysis can be affected by inaccurate data from the hospitals. We are able to spot, and re-code, in the case of some errors-for example, if diabetes were coded as acquired in the hospital, we would re-code it as present on admission. But there are some types of secondary diagnoses for which coding errors would not be obvious and correctable. So there is still some possibility that our results could be affected by coding errors.

    • Because of data limitations, various underlying characteristics of patients could not be considered. Suppose, for example, you are looking at a public hospital that caters to low-income, uninsured patients. There's a good chance that the hospital's patients might have social problems—such as the absence of emotionally supportive family members—that are not reported in the data available for analysis but that might affect death rates within 30 days of hospital admission.
    • Within any one of the types of cases we looked at, patients may have diseases at different stages of progression, with very different risks of death. Some hospitals' pneumonia cases, for example, might include a disproportionately large number of cases in which the disease was at an advanced stage by the time the patient was admitted. The data we were working with did not include information on laboratory or x-ray results, which would make it possible to distinguish among patients on the basis of these findings. Undetected differences in patient mix are especially likely when comparing hospitals if one hospital is a regional referral center to which other hospitals send their difficult cases.
    • Cases were followed for only up to 30 days after admission. Problems caused by some hospitals may not result in death until later than that. (Longer follow-up periods, of course, have their own set of problems since more time increases the chances of death from causes unrelated to the hospital stay.)
    • Some differences in death rates may result from differences in community practices or in the availability of non-hospital facilities to care for patients. In some communities, for example, patients in final stages of emphysema (obstructive pulmonary disease) may be allowed to die in their homes or in nursing facilities, while in other communities these patients may be admitted to hospitals for their final few days.
    • Some of the data for some hospitals may not be accurate. There are, no doubt, many innocent errors when so many records are processed by hospital coding staffs. In addition, it is likely that hospitals follow different coding guidelines in describing diagnoses in the records they report to Medicare in their efforts to get the highest allowable reimbursements for the cost of care.
    • Some of the data are incomplete. For example, the billing record that is the source of the data has space for hospitals to list only eight secondary diagnoses in addition to the principal diagnosis. If a patient had nine or more secondary diagnoses, the adjustment process was not able to allow for the secondary diagnoses in excess of eight.
    • Time has elapsed since the period to which the data apply. The Medicare records of hospital cases don't become immediately available to the public or to researchers, and it took time for us to do our analyses.
    • The data are for patients 65 or older. It is possible that hospitals that perform well with that age group don't do so well with younger patients.
    • High or low hospital death rates may result from the quality of treatment provided by specific doctors, not from the quality of the hospital's performance. If a hospital does well because of specific doctors, that may do you no good if you use a different doctor.

    To use our data on death rates, first look for categories of cases like yours on the "Specific Cases" tabs. If you are looking for a hospital to use for major bowel surgery, for example, look for hospitals with adverse outcomes rates that were significantly Better than predicted in that category.

    If your case doesn't fit any of the categories on our table, or if you are selecting a hospital in advance of the need (for example, as a consideration in choosing a physician or HMO), look for a hospital with a favorable score in the "all selected cases" category and possibly in several other categories of cases of interest to you.

    It is interesting to note that hospitals that had significantly better-than-predicted mortality rates in the "all selected cases" category also tended to get higher ratings than other hospitals from surveyed physicians. As the figure below shows, the hospitals that had significantly better-than-predicted mortality rates were rated "very good" or "excellent" on average for "surgery on an adult in cases where the risk of complications is high" by 41 percent of surveyed physicians. Hospitals that had significantly worse-than-predicted mortality rates got such favorable ratings from substantially fewer surveyed physicians (only 29 percent).

    Doctors vs. Death graph

    Be sure to discuss the death rate data with your doctor. Ask for any information he or she has that might explain an especially high or low adjusted death rate. In addition, we recommend asking hospitals for their comments on their death rates. Call the hospitals' public relations departments.

    Rates of Adverse Outcomes

    The death rate information we have presented focuses only on one bad outcome: death. But there are other bad outcomes. You don't want to contract an infection in the hospital, have a bad reaction to a drug, fall out of bed, or have any of many other types of complications even if you ultimately survive. Some complications cause permanent disability or disfigurement; others just make your hospital stay longer and more unpleasant. You want neither.

    To give you information that might alert you to high complication rates, we took a roundabout approach. We looked for complications only in surgical cases. Our assumption was that for most of the surgeries, timing was discretionary, and patients would not generally be admitted to a hospital for surgery if they currently had an infection or some other medical problem that might be expected to go away if the surgery were simply delayed. Using these cases, Michael Pine and Associates, which did the analysis for us, developed a proxy indicator for complications in cases where death did not occur within 30 days of hospital admission. The proxy indicator is intended to highlight complications regardless of whether they are reported as such in the hospital records. This proxy indicator looks for prolonged hospital lengths of stay. Analyses of medical records have shown that a large proportion of prolonged lengths of stay are associated with important complications.

    Here is a simplified explanation of how that analysis was done. The analysis recognized that, for a given category of cases, a given hospital will have varying lengths of stay, even after allowing for differences in patients' characteristics. But after allowing for differences in patient characteristics, most of this variation will be clustered around the hospital's average length of stay for that category of cases. Cases in which the length of stay is not within a hospital's predicted cluster are likely to involve complications. For each category of cases for each hospital, the analysis identified cases that had lengths of stay outside the predicted cluster of lengths of stay. These were deemed to be prolonged lengths of stay. Such prolonged lengths of stay, like deaths, might occur more often in hospitals with especially sick or frail patients, so the analysis calculated a predicted percentage of prolonged lengths of stay for each hospital based on the mix of characteristics of the hospital's patients.

    The predicted percentage of prolonged lengths of stay was then combined with the predicted percentage of deaths to come up with a predicted percentage of "adverse outcomes" for each hospital. At the same time, the actual percentage of prolonged lengths of stay was combined with the actual percentage of deaths to come up with an actual percentage of "adverse outcomes" for each hospital. The predicted adverse outcome rate was compared to the hospital's actual adverse outcome rate to calculate a ratio that was in turn used to calculate a risk-adjusted adverse outcome rate. This was done by following the same steps, described above, that were used in calculating a risk-adjusted death rate from the actual, predicted, and all-hospital death rates.

    The overall risk-adjusted adverse outcome rates for each hospital, which take into account both deaths and prolonged lengths of stay, are shown on the Death and Adverse Outcomes Rates-Overall tab. On the Death and Adverse-Outcome Rates for Specific Medical and Surgical Cases tab, we also report for each hospital whether its actual adverse outcomes rate is significantly different from the predicted adverse outcomes rate for several specific types of surgical cases.

    It is important to keep in mind that most of the caveats set out above with regard to adjusted death rates also apply to adjusted adverse outcome rates. In addition, while the death rates measure directly something we care about—death—the adverse outcome rates use a proxy—length of stay—as an indicator of the thing we care about—complications.

    Surprisingly, we found no substantial relationship between adjusted death rates and adjusted adverse outcome rates (once we eliminated deaths from the adverse outcome rates). While these two rates are measures of different types of outcomes, one might expect that hospitals that are relatively good at preventing complications would also be relatively good at preventing deaths. But similar analyses done by others, also looking at complications and deaths, have had similar findings. When we ranked hospitals, we put weight on death rates rather than on adverse outcome rates, but both types of rates appear on our Ratings Tables.

    How Often Hospitals Performed the Proper Tests and Treatments

    These scores are derived from data published at the federal government's Hospital Compare website.

    The scores we report show the overall percent of instances in which the hospitals performed the proper tests or procedures for four common case types. To calculate these scores, the federal government examined patient records for each hospital and assessed how often hospitals gave recommended tests or treatments known to get the best results for patients with certain medical conditions or who had undergone certain surgical procedures. This analysis examines, for example, how often hospitals gave heart-attack patients aspirin upon arrival or how often hospitals gave proper antibiotics to prevent surgical infections.

    The federal data report on four different medical case types, and for each indicate how often each hospital did what it should have done according to a set of guidelines. The case types were: heart attack (seven measures of care), heart failure (four measures), pneumonia (seven measures), and surgical infection prevention (seven measures).

    The score we show on our Ratings Tables for "all selected case types" is an aggregate score calculated across all measures for the four conditions. (In other words, we added up all of the instances where a given hospital did the proper tests and/or treatments across all reported measures, and then divided that total by the total number of times the hospital had an opportunity to perform the proper tests and/or treatments.) On the Ratings Tables, we show how hospitals scored, in aggregate, across each of the four case types.

    On our Ratings Tables, we have used Green type to highlight the highest scores and we have marked in Red type the lowest scores.

    One limitation in these data is that the recommended care may not always be the best treatment for everyone. For example, someone who has recently had a heart attack should be given aspirin as soon as possible upon arrival at the hospital—but not, of course, if that patient is allergic to aspirin. Unfortunately, the federally reported data cannot always take into account patients who should not have received generally recommended care.

    Patient Ratings

    The ratings from patients shown in our Ratings Tables come from federally sponsored surveys, using a standardized questionnaire and survey procedure. The survey asked a random sample of recently discharged patients about important aspects of their hospital experience. The survey attempts to collect at least 300 completed surveys for each hospital every year.

    On our Ratings Tables, we have used Green type to highlight the highest scores and we have marked in Red type the lowest scores

    When using these data, keep in mind that the mix of patients can differ from one hospital to the next, and these differences in patient mix can affect a hospital's survey results. The analysis has tried to take into account these differences so that survey results reported are what would be expected for each hospital if all hospitals had a similar mix of patients, but these adjustments might not completely ensure fair comparisons for all hospitals.

    Also, the content of several of the questions is to some degree subjective, and you may have different critical standards than those of the surveyed patients.

    Interestingly, as this figure indicates, hospitals that got relatively high ratings from the doctors we surveyed also tended to get relatively high ratings from surveyed patients.

    physiciansAndconsumers

    Hospitals are not required to participate in the survey of patients, although most larger hospitals will get somewhat lower reimbursement rates on their claims for Medicare patients if they do not participate. We believe all hospitals should participate (with the possible exception of very small hospitals that have too few patients to yield a meaningful sample of patient survey responses.)

    Teaching Programs

    On Ratings Tables, we show which hospitals had major affiliations with medical schools according to federal government records. An affiliation with a medical school generally means that various doctors and medical students check patients' records and interview the patients. That can result in your getting a variety of perspectives brought to bear on your case. Also, doctors who are at the cutting edge of research and practice tend to have at least some of their practice at hospitals affiliated with medical schools. This means that the doctors practicing at these hospitals tend to be exposed to the newest developments and to have their ideas challenged by sophisticated colleagues. In addition, hospitals affiliated with medical schools are likely to have advanced diagnostic and treatment equipment.

    On the other hand, hospitals affiliated with medical schools are generally larger than average. The care may be relatively impersonal. And it can be annoying to be bothered by a stream of students and trainees, all with an academic—but often not very personal—interest in your case.

    Doctor vs. Med. School graph

    This figure the relationship between major medical school affiliation and physician ratings. As you can see, the hospitals with major medical school affiliations were rated much higher than other hospitals by surveyed physicians. And as shown on this figure, hospitals with major medical school affiliations also tend to have slightly (but statistically significantly) better adjusted mortality rates for all selected cases than other hospitals.

    Death vs. Med. school graph

    How Many Cases

    Many studies have concluded that, in some types of cases, hospitals that handle large volumes of cases have better results than other hospitals—that, in effect, practice makes perfect. Our tables don't report on hospitals' volumes for specific types of cases, but you can ask your doctor or the public information staffs of hospitals you are considering how many cases like yours they handle each year. Your doctor may have to help you define your case type in a precise enough way for the information to be meaningful.

    At a very general level, we have reported on the Ratings Tables the total number of Medicare cases each hospital discharged over a four-year period for the selected medical and surgical case types we used for our death rate analysis. This gives you a rough indicator of hospital size. Interestingly, as this figure shows, the larger hospitals (those with more cases in this total case category) had somewhat lower adjusted death rates for "all selected [medical and surgical] cases" than hospitals with lower total numbers of cases.

    Death vs. Cases graph

    Leapfrog Hospital Safety Score

    These data come from The Leapfrog Group, an organization that tracks and encourages hospitals' efforts to improve patient safety. The Hospital Safety Score is an A, B, C, D, or F letter grade reflecting how safe hospitals are for patients. Scores are based on Leapfrog's analysis of hospital safety performance in dozens of areas, including results from Leapfrog's own surveys of hospitals. For detailed information on how these scores were derived, visit www.hospitalsafetyscore.org.


    Other Information You Can Gather On Your Own

    In addition to the information on our tables, there is additional information you can gather on your own.

    The Hospitals' Doctors

    If you have a strong relationship with a physician who would care for you during a hospital stay, you will want to be wary of making a hospital selection that will force you to give up, or strain, that relationship. This is especially true if your case is one—knee ligament surgery, for instance—in which there is low risk of hospital-caused death or serious complications, but surgeon-to-surgeon differences in outcome in terms of your ability to function as you would like are substantial.

    Before letting a physician relationship dictate choice of hospital, check whether the physician you prefer can be flexible. If it is your primary care physician whom you want involved in your case but you are going to have surgery or some other treatment that will be managed by a specialist while you are in the hospital, you might want to choose a specialist affiliated with the hospital you would prefer. You can ask your primary care physician to arrange to communicate regularly with that specialist.

    Also, before choosing a hospital based on a physician relationship, be sure the physician or physicians you are counting on will actually be caring for you. Find out which doctor will be in charge of your care in the hospital. Will it be your primary care doctor, a surgeon, or some other doctor? If you have arranged for surgery from a well-known surgeon, make sure that this is the surgeon who will actually do the hands-on surgery. Some big-name surgeons set up and supervise surgery but leave it to their assistants to do most of the work; if that is the plan, you might want to change surgeons.

    Regardless of whether you currently have a strong relationship with a physician, one way to judge hospitals is by checking whether they have high-quality physicians affiliated with them. The best physicians are not likely to send their patients to low-quality hospitals. If there are physicians you know to be excellent, find out which hospitals they use. Our Guide to Top Doctors is a source of names of top-quality doctors whose hospital affiliations you can check out.

    Special Services

    You might want to consider whether a hospital has special programs and strengths of kinds that are not addressed on our data tables. For example, if you are likely to need rehabilitation services, you might want a hospital that has strong capabilities in that field. You can ask your physician which hospitals have such special capabilities. You can also check with your state or local hospital association. The list below includes hospitals that specialize in one type of care, cancer care.

    Consumer Observations

    You can learn a lot of important information about hospitals by making your own visits or talking with other consumers who have been patients in, or regularly visited, available facilities. The best way to learn about a facility is to observe when visiting friends of loved ones (or being a patient, of course), but you can also learn by calling the administrator's office at any hospital you are considering and arranging a tour. There's much to consider—

    • Check the rooms. Are they roomy enough? How noisy are they? Is there privacy in patient beds and in bathrooms—from the hall and from the other patient in semi-private rooms? Are private rooms available and at what cost? Are the rooms clean and attractive? Are there windows with a pleasant view? Is there good lighting? Is there an easily accessible call button at bedside and in the bathroom? Are TV sets placed where they can be easily viewed? Can headphones be arranged so that you and your roommate, if you have one, can avoid disturbing one another? Is there air conditioning? Can temperatures be controlled on a room-by-room basis?
    • Check the halls. Are they clean? Are they free of foul smells? Are they free of heavy smells of deodorizers that might be masking cleanliness problems?
    • Check the other patient areas. Are there pleasant sitting areas and places where patients can walk close to their rooms? Can patients walk or sit outside in a safe and convenient place on pleasant days? Are there a cafeteria, newsstand, lobby, and other facilities that will make the hospital pleasant for visitors?
    • Ask for a list of hospital policies. Are the visiting hours reasonable? What are the hours for receiving phone calls? Can children visit? How much flexibility is there on mealtimes and bedtimes? Can arrangements be made for a relative or close friend to sleep-in near the patient? In general, do policies seem reasonable?
    • Check the staff. Do nurses and other staff members seem responsive to patient needs? Do they respond promptly when called? Do they take the time to listen and answer questions? Are they gentle? Are they respectful? Do they seem competent?
    • Check the food. Does it seem fresh and attractive? Are fresh fruits served, and are fresh vegetables not overcooked? Do hot meals arrive hot and cold meals cold? Do patients who are not on physician-ordered diets have any choice of meals? Can arrangements be made for vegetarian, kosher, or other special diets?
    • Check the social work services. What are the staff's capabilities for arranging needed services after discharge? Do they follow through?

    The data on the Ratings Tables in this guide relate to serious, high-risk cases. Even in such cases, having pleasant surroundings, good meals, and other comforts will be important to you, but these features deserve special weight in low-risk cases. In all cases, it is very important that family and friends can conveniently visit you. Visitors can bolster your morale and thus speed your recovery. The presence of visitors puts the hospital staff on notice that someone cares about you; that might make the hospital staff more attentive also. In addition, having family or friends to observe the care you are getting is critical. They can help you look out for medication errors, gaps in staff followup, inattention to your pain, hospital routines like middle of the night wakeups that are unnecessarily disruptive, and many other care and service problems. And they can speak up on your behalf.

    Talking with Your Doctor

    The information on individual hospitals reported in this guide and gathered on your own will help you in selecting a hospital. We strongly recommend that you discuss the data with a physician or physicians you trust. This discussion should be a two-way street; your opinions, information, and preferences matter. If your physician recommends a facility that you would not have chosen, ask why. Keep in mind that physicians may have reasons for hospital choice that are unrelated to your well-being. Your doctor might find it more convenient to have all his or her patients in the same facility. Within a managed care plan, there may be financial penalties for the doctor if the doctor doesn't use specific hospitals. You at least deserve to have an explanation of the reasons your doctor thinks a specific hospital is best for you.


    How to Get Good Care Wherever You Go

    Regardless of which hospital you are admitted to, you and your family or friends can do a lot to influence the quality of care you receive. What matters most is your attitude. It is important that you feel involved in, and responsible for, your own care—that you view the hospital and staff only as the setting and the means to help you get well.

    Before You Arrive

    If there is time, a little care in getting ready for your hospital stay will serve you well later on.

    If you will be getting care from a surgeon or other specialist, meet with this doctor. Get a full explanation of exactly what will be done. Get an understanding of who will be doing your surgery and what role assistants might play. Find out who will be caring for you as you recover after surgery and after you leave the hospital. If you are not happy with the answers, this would be the time to change doctors.

    If you will be having surgery, try to meet also with the anesthesiologist. It is better to have this meeting in the more relaxed atmosphere of an office visit than to meet with the anesthesiologist, in the typical way, for a few hurried minutes right before the operation. Arranging an appointment in advance is not easy to do (and be sure to confirm that your insurance will cover it), but it is worthwhile, given the importance to your safety of his or her work. You can ask your surgeon to give you the name of the anesthesiologist and to help you make an appointment. When the anesthesiologist asks questions, be sure to give thorough answers—about high blood pressure, heart problems, allergies, or other conditions that might put you at risk when under anesthesia. Also, confirm that the anesthesiologist will actually be present with you in the operating room, not a subordinate.

    If you might need blood transfusions in connection with surgery, ask your surgeon whether autologous transfusion makes sense for you—giving your own blood and having it stored for your own later use. You might be able to give a unit a week for several weeks before surgery.

    Decide whether you will want a private or semi-private room. With a private room, you avoid any problems with roommates who might be noisy or have annoying visitors. But sharing a room with someone else gives you a little company, is likely to increase the frequency of nurse visits to your room since there are two patients to visit, and gives you someone who might be able to call for help for you in a crisis.

    Think carefully about packing for the hospital. Be sure to take a toilet kit with toothbrush, shampoo, deodorant, and other items just as you would if you were going on a vacation. Also, bring along a clock, things to read, and things to write with. And bring pajamas, a robe, and non-skid slippers.

    Don't bring a valuable watch or expensive jewelry. They might get stolen. You will not be able to keep an eye on it all the time—certainly not when you are in surgery or recovery. Don't bring more than a few dollars in cash. Bring a cell phone if you have one; if not, bringing a phone card is a good idea if you will want to make out-of-area calls. You might want to bring a few pictures to keep you company and possibly a few other items of sentimental value, but label anything you bring with your full name and realize that you might lose it.

    Check in advance with your doctor which of your regular medications, including vitamin supplements, you will be continuing to take while in the hospital. Bring a list of these medications, noting the dosage and frequency. If you bring the actual medications, have your doctor mark in your medical record that you are to take these medications and that the nurses are to find a place to store them; be sure to label them clearly as yours. Bring them in their original bottles with labels.

    Make arrangements for where you will go and how you will be cared for after discharge. You may not know in advance what condition you will be in after release, but it is wise to talk with your doctor about the possibilities and to make at least preliminary arrangements.

    Monitor Your Own Care

    Learn as much about your condition as possible before going to the hospital by talking to your doctor and doing research in libraries and on the Web. Ask your doctor to tell you what treatment is recommended, what alternatives are available, and the consequences of each. Find out what medications, if any, you will be taking, what they look like, and any possible side effects. If you and your doctor go over these things before you are in the hospital, you will be better prepared to deal with each treatment step and less likely to be surprised or feel pressured about making decisions.

    During treatment, keep notes on the results of tests. Also keep track of changes in medications or diet and their effects.

    Write down questions you want to ask the doctor or the unit's head nurse during his or her visit and record the answers.

    By keeping track of these things, you will know more about your condition and what to expect. You will also know enough to question the arrival of an unexpected meal or a new pill. It may not be yours.

    Be Yourself

    Simply as a part of being in the hospital, many people become more passive and dependent than usual. Inactivity and concern about your condition contribute to this; so does the typical hospital routine of frequent interruptions and continual waiting—for meals, tests, visits from the doctor and friends, and medication. To help you be yourself, try to personalize your day and your surroundings by putting out a few personal (not valuable) items from home, by wearing your own clothes where possible, by calling friends and asking them to bring you snacks (provided you are not on a restricted diet), or by doing some work or reading. If not disruptive to others or harmful to your condition, these kinds of activities might help you resist becoming excessively reliant on the hospital and staff—and will help to assure that staff members regard you as a person, not just a case. We know one patient who purposely wore bright red pajamas and did aerobic exercises every day just so she would not be typed simply as "thyroid tumor in 302."

    In general, do all you can for yourself. No one expects you to jump out of bed hours after you come out of the operating room. But as you and your doctor feel you are able, try to feed yourself, get out of bed by yourself, and generally take on as much as you can of your own care. This is therapeutic for you and will gain you the respect of the staff.

    Be sure to express your appreciation for the good care you receive. Nurses have a demanding job and, like everyone else, need a little feedback. If one of your visitors can bring a gift or some flowers for the nurses, rather than for you, that will be appreciated. Also, learn your nurses' names and call them by name.

    Protect Yourself

    Given the high risks of infections, drug errors, and other hospital mishaps, it is essential that you take steps to protect yourself. If this means you are not the most agreeable patient, so be it. This is a matter of life and death.

    Protect Yourself Against Infections

    Hospital-caused infections are a major killer—and a major cause of suffering, anxiety, and extended hospital stays. Making Health Care Safer, a report issued by the U.S. Agency for Healthcare Research and Quality, stated that such infections "occur in seven to 10 percent of hospitalized patients and account for approximately 80,000 deaths per year in the United States."

    Most infections are the result of the spreading of "germs" from patient to patient on the hands of physicians, nurses, and other hospital workers. The best way to reduce this problem is very low-tech: the people who touch you in the hospital just need to wash their hands. Numerous studies have demonstrated that handwashing sharply reduces rates of patient infections. Although this has been known for 150 years, hospital workers simply don't always follow the basic rules of hygiene. Most healthcare workers understand the importance of handwashing but simply don't do it consistently—and aren't even aware of how poorly they are doing.

    The solution for you? Ask every healthcare worker—including your doctor—who will be having direct contact with you to wash his or her hands before touching you, your food, your medications, or equipment that will come into contact with you. Studies have found that one of the most effective ways—better than training programs or rewards and punishments-to get health care workers to wash their hands is for patients to ask them to do so.

    Washing hands with disinfectant soap and water is one effective technique. But it takes 15 to 30 seconds to do it right; it takes time for the hands to dry; and washing hands many times per day can be irritating to the skin. A faster, less irritating, and equally effective alternative is hygienic hand-wipes.

    Take to the hospital with you a supply of sanitizing hand-wipes, which you can buy in the drug store, and keep them in a prominent place at your bedside. These alcohol-based hand-wipes generally have emollients that make them easy on the skin.

    You may feel awkward interfering in the health care workers' routines. Overcome it. Be polite, but not passive. The stakes are too high. Some hospitals have found that instructing patients at admission that the patients should ask every healthcare worker to wash his or her hands is an effective way to increase handwashing compliance. But hospitals don't typically take this approach. You need to do it on your own. You can simply explain that you are doing as you were told by a book you read.

    Ask also about equipment that will come into contact with you. That stethoscope should also be cleaned with a sanitizing wipe. Contaminated catheters, infusion pumps, endoscopes, and bronchoscopes can also be a problem, though one you will have a harder time monitoring.

    If your roommate or the roommate's visitors show signs of contagious illness, like sneezing or coughing, ask your doctor about changing rooms.

    Protect Yourself Against Drug Errors

    The Institute of Medicine report, To Err Is Human, highlighted the shocking frequency of medication errors in hospitals. The Institute cited numerous studies to document the problem. For example, one study of a 37-day period in a sophisticated urban hospital found 27 cases of "injury resulting from a medical intervention related to a drug."

    Hospitals could do, and long since should have done, much to reduce this problem, including the introduction of Computerized Physician Order Entry (CPOE) systems. But there is also a lot you can do to protect yourself.

    The key is to have a written list of the medications—including medications taken via IV hookup—you will be receiving, why, how often, and what the proper dosage is. If a medication looks different from what you have been getting, stop and ask the nurse about it. Maybe it is just a generic-equivalent substitute, but maybe it is the wrong drug. Be sure the hospital staff knows about all the medications you and your doctors have agreed you will be taking.

    Make notes of when you get medications. If you don't get one on schedule, ask the nurse why not. You and the nurse can confirm the missed dose by checking your chart.

    If you have an unexpected reaction to a drug, bring it to the attention of the nurse immediately. Some, but not all, of the types of reactions to look out for are tightness in your chest, shortness of breath or trouble breathing, pain, burning sensations, dizziness, confusion, numbness, or itching.

    Avoid Falling

    Hospital patients are at substantial risk of falling, even patients who are young and strong and would not normally be considered to be at risk. You may be weak from illness or injury or from too much time in bed, or you may be dizzy or confused from medications. Falls can cause hip fractures, other types of fractures, concussions, or other injuries.

    There are various precautions you can take to avoid falling—

    • Before getting out of bed sit still on the edge of the bed with your feet dangling until you are sure you have your balance. If you still feel at all unsteady, call a nurse or aide to help—and wait for the help.
    • If you have been instructed not to get up without help, follow that instruction.
    • Keep your eyeglasses by the side of your bed. Be sure you can see normally, that your vision is not suffering from side effects of treatment, before trying to walk.
    • Wear slippers that have non-skid soles and that will stay on your feet. If there are wet spots on floors, ask someone to dry them before proceeding.
    • Make sure that furniture is not in your way. Before going to bed at night, check that furniture is arranged so that it won't interfere with you if you have to go to the bathroom.
    • Take your time. Even a few days in the hospital can sap your strength. Use a walker if that will help.
    • Don't get out of bed until your bed is cranked down and never try to climb over raised side rails. Ask a nurse or aide to fix your bed so that you can get out.

    Be Able to Get Help When You Need It

    When you first arrive in your room, locate the call buttons at bedside and in the bathroom. Tell the nurses that you want to test them, and do so.

    When you use a call button, you should expect an immediate response—at least by intercom—to find out how urgent your need is.

    If you don't get a quick enough response, call again. If you feel desperate, use your outside phone line to call the hospital and ask to be connected to the nursing station that serves your room number. If that, too, fails to get a response, call your doctor.

    Insist on Attentive Nursing Care

    Expect at least the following from the nursing staff—

    • Nurses should observe you every few hours if you are not seriously ill-every few minutes if you are critically ill.
    • They should spend time with you to ask about any changes in your condition, any pain, any new complaints.
    • They should call your doctor if an unexpected change occurs—or if you are concerned enough that you think the doctor should know.
    • There should be some continuity of the nursing staff—not a constant daily turnover of new faces.

    Don't Get Cut in the Wrong Place

    Wrong-site surgery—operating on the wrong body part—is the kind of mishap that gets dramatic attention in the press. Fortunately, it is not very common. Unfortunately, it is still too common.

    A key measure to avoid such catastrophes is to mark the surgery site with a permanent marker, during a preoperative visit, before the day of the operation. Such marking has become standard procedure among competent health care providers. For example, in 1998, the American Academy of Orthopaedic Surgeons endorsed a surgical site identification program called "Sign Your Site." Ask your surgeon what site-marking procedure he or she uses, and then mark the site together while you are at the doctor's office.

    Take Charge of Communication

    Be sure the nursing staff knows about your conditions—what you are in the hospital for and other conditions that might affect the care you should receive. Hospitals are big places. Hospital workers care for dozens of patients every day. One worker takes over when another worker goes home. A lot of information can get lost in the shuffle; confusion can ensue. Computerized medical records, if properly used, would help. But most hospitals are shamefully backward in implementation of such systems, relying instead on the same types of patient records they have used for many years. It is, unfortunately, important for you, if you are able, to keep track of what is going on and make sure the right information gets from one caregiver to another.

    First, make sure they know who you are. Make sure your wristband is accurate. To help everyone keep things straight, use a piece of posterboard to make a sign with your name, serious allergies, and chronic medical conditions and post it at the head of your bed. Some hospitals actually supply posters for this purpose.

    Be particularly vigilant at shift changes—to be sure the new folks know what went on, or didn't go on, on the previous shift. The sign-out procedures used in most hospitals when a physician goes off duty to pass information to the "cross-covering" physician who will take care of patients in the interim is often informal and unstructured. Errors are more likely to occur during the coverage period of the cross-covering physician than when the regular physician is on duty.

    Keep a log of what happens to you each day. If something seems to have been missed, or if there is an attempt to repeat some test or treatment that you think is unnecessary because it has already been done, ask about it. Refer to your log and your medical record.

    Eat Right

    Eating right is important for you to feel right when you are at home, so it's not surprising that it is also important when you are in a hospital. Unfortunately, that is not always easy. The food often leaves a lot to be desired. If the food is not as hot or as cold as it should be, ask the staff if that can be improved. If you find it just too unpleasant to eat, ask your doctor to authorize you to get food from the outside and ask friends to bring meals to you. Ask to have a small space arranged for you to store your food in a hospital refrigerator. Be sure to label it.

    If you routinely take vitamin supplements, get your doctor's permission to take them in the hospital. Even if you don't take such supplements regularly, they might make sense for you in the hospital since your other nutritional intake may be deficient. Ask your doctor to arrange for your vitamins to be properly labeled, stored, and dispensed by the nursing staff.

    Ask to see a hospital dietician if you have problems with food. Eat well, but be sure to follow orders about not eating before surgery.

    Demand the Basic Comforts

    It is important to your recovery that you be as comfortable and happy as possible. If your roommate or the roommate's visitors are too noisy, discuss it with your roommate. If that doesn't work, or if something your roommate can't control like incessant coughing is making it very difficult for you to relax or sleep, ask to have your room changed. If there is too much noise in the hall, ask what can be done about that. Another possible solution to noise problems watching TV or listening to the radio or music with headphones.

    Negotiate about schedule. If the staff routinely wakes you up three times in the middle of the night, ask whether all those disturbances are needed. See if you can take the medication or have the readings taken right before bedtime or right after you wake up. If you are normally a late sleeper, see if your normal schedule can be accommodated. If you don't want sleeping pills, ask not to be given them.

    If you want someone to sleep-in with you, ask for that to be arranged. A comfortable chair should be arranged, and many hospitals will provide cots.

    Don't Accept Treatment without Your Consent

    You have a right—based on law and on medical ethics—to be treated only after giving your informed consent. Before surgery, you will be asked to sign a consent form. In the absence of consent, a surgeon's cutting you open with a knife would be deemed negligence in some states, battery in others. Yet studies have found that substantial percentages of patients do not fully understand what their physicians have described about a procedure, and many would like more explanation.

    If you don't understand the risks, the benefits, the alternatives, and other important aspects of a procedure, ask for more information. Do this even if you have already signed a consent form. It is not too late to change your mind right up until the procedure begins. This applies not only to surgery, but also to radiology procedures, drug treatments, blood transfusions, and other procedures that may pose risks to you.

    Consider Carefully Participation in Clinical Trials

    You may be offered a chance to participate in a clinical trial. A clinical trial is research in which the use of new drugs or medical devices is tested in humans. The purpose of such trials is to learn whether new treatments will benefit future patients.

    Although the new treatment being tested might be better than alternative treatments, it might be worse. Also, if you participate in a trial, you might be assigned to the "control" group that gets a standard treatment rather than the new treatment. (In cases of life-threatening disease, control groups virtually always get a treatment that has been judged to have some value, not just no treatment at all.) There is some evidence that patients who have participated in trials have survived longer than patients who chose to get treatment outside a trial. An explanation for such a difference might be that patients in a trial may receive closer medical attention and more follow-up visits than patients who are not in a trial.

    A very valuable resource to help you make a decision about participation in a clinical trial is Should I Enter a Clinical Trial?, a guide prepared by ECRI, a nonprofit health services research organization. The guide is available at www.ecri.org. Drawing on the guide, we list below several types of information you will want to get to help you decide whether to participate in a clinical trial—

    • A summary of results from previous trials that led to this trial.
    • The purpose of the new research-what it is trying to achieve.
    • How long the trial will last for you if you remain in it to the end.
    • A detailed description of each test and treatment that will be given according to the trial plan.
    • The timing and the location of those tests and treatments and how they are scheduled for you.
    • Identification of any procedures that are experimental.
    • A description of any reasonably foreseeable risks or discomforts to you (for example, pain or minor and major side effects) from any test or treatment that will be given.
    • A description of any possible benefits to you or to others.
    • A description of any alternative procedures or courses of treatment that might be advantageous to you.
    • A statement that participation is voluntary and that you may refuse or discontinue participation at any time without penalty or loss of benefits.
    • A statement that you will be informed of significant new findings that may relate to your willingness to continue to participate in the trial.
    • An itemization of any costs to you as a result of participation.

    • A description of anticipated circumstances under which the investigator may terminate your participation without regard to your consent.
    • A description of the consequences of your decision to withdraw, if you decide to do so, and the procedures for withdrawal.
    • The approximate number of participants involved in the study.
    • A full disclosure of any financial interests the participating researchers and institutions have in the research.
    • Travel and lodging information for you and loved ones accompanying you.
    • A description of support that you might require from family and friends for daily activities or daily needs while in the trial.
    • A statement describing the extent to which confidentiality of your records will be maintained.
    • An explanation of whether any compensation and/or medical treatments are available if injury occurs from treatment in the trial and, if so, what they are and who will provide them.
    • Information on whom to contact with questions about the trial and your rights.
    • Information on whom to contact in the event of a research-related injury.

    Don't Suffer Pain Silently

    Nearly half of all surgery patients do not receive adequate pain relief. The practice of delaying or withholding pain relief medications due to fear of masking symptoms is widespread. Many patients mistakenly worry that taking pain medication will lead to addiction. Inappropriate treatment of pain results from poor understanding and skills of providers and inadequate patient education. The American Pain Foundation (APF), an organization devoted to educating consumers about pain, wants consumers to have the following facts about pain, whether in-hospital or elsewhere—

    • Pain is not something you "just have to live with." Treatments are available to relieve or lessen most pain. If untreated, pain can make other health problems worse, slow recovery, and interfere with healing. Get help right away, and don't let anyone suggest that your pain is simply "in your head."
    • Not all doctors know how to treat pain. Your doctor should give the same attention to your pain as to any other health problems. But many doctors have had little training in pain care. If your doctor is unable to deal with your pain effectively, ask the doctor to consult with a specialist, or consider switching doctors.
    • Pain medications rarely cause addiction. Morphine and similar pain medications, called opioids, can be highly effective for certain conditions. Unless you have a history of substance abuse, there is little risk of addiction when these medications are properly prescribed by a doctor and taken as directed. Physical dependence—which is not to be confused with addiction—occurs in the form of withdrawal symptoms if you stop taking these medications suddenly. This usually is not a problem if you go off your medications gradually.
    • Most side effects from opioid pain medications can be managed. Nausea, drowsiness, itching, and most other side effects caused by morphine and similar opioid medications usually last only a few days. Constipation from these medications can usually be managed with laxatives, adequate fluid intake, and attention to diet. Ask your doctor to suggest ways that are best for you.
    • If you act quickly when pain starts, you can often prevent it from getting worse. Take your medications when you first begin to experience pain. If your pain does get worse, talk with your doctor. Your doctor may safely prescribe higher doses or change the prescription. Non-drug therapies such as relaxation training and others can also help give you relief.

    The APF has issued a pain care bill of rights. Although these are not legal rights, they are standards that you should expect to have observed. According to the APF, you have—

    • The right to have your report of pain taken seriously and to be treated with dignity and respect by doctors, nurses, pharmacists and other healthcare professionals.
    • The right to have your pain thoroughly assessed and promptly treated.
    • The right to be informed by your doctor about what may be causing your pain, possible treatments, and the benefits, risks, and costs of each.
    • The right to participate actively in decisions about how to manage your pain.
    • The right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased.
    • The right to be referred to a pain specialist if your pain persists.
    • The right to get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose.

    Remember, you have a role here. You must communicate about your pain to your doctors and nurses.

    Have Your End-of-Life Wishes Prevail

    At some point, patients, their families, and friends may have to decide whether to extend life-sustaining treatment with measures such as resuscitation, endotracheal intubation, feeding tubes, and administration of IV fluids. If you want your end-of-life wishes honored, you will need to have discussions with your family or other representatives and your physician in advance. Good communication at the end of life can also help patients achieve closure and meaning in the final days of their life.

    In 1990, the Federal Patient Self-Determination Act was passed by Congress to encourage competent adults to complete advance directives. The act requires hospitals, nursing homes, health maintenance organizations, and hospices that participate in Medicare and Medicaid to ask if patients have advance directives, to provide information about advance directives, and to incorporate advance directives into the medical record.

    Advance directives are any expression by a patient intended to guide care, should the patient lose his or her medical decision-making capacity. Although both oral and written statements are valid, the added effort required to complete written statements gives them greater weight. In addition to their use when patients lose competence, advance directives also help patients consider the type of care they would want in the future, even if they retain decision-making capacity. Advance directives have legal validity in almost every state

    There are two principal forms of written advance directives: living wills and durable powers of attorney for healthcare. A living will is a document that allows you to indicate the interventions you would want if you were terminally ill, comatose with no reasonable hope of regaining consciousness, or in a persistent vegetative state with no reasonable hope of regaining significant cognitive function. A durable power of attorney for healthcare is a more comprehensive document that allows you to appoint a person as a proxy to make healthcare decisions for you should you lose decision-making capacity.

    Unfortunately, the potential for advance directives to guide patient care is often not realized. Many patients don't complete such directives, and often the directives are not available or adequately communicated at the time end-of-life decisions must be made. Even when a written advance directive document is prepared, it may not meet its objective. One study found that only 12 percent of patients with an advance directive had talked with a physician when completing the document and only 25 percent of physicians were aware of their patients' advance directives. One study that surveyed elders in community settings found that 81 percent desired to discuss their preferences with their physicians if they were terminally ill, but only 11 percent had done so. In one survey of 200 patients, only 18 percent had filled out an advance directive and of these, 50 percent had secured the only copy in a safe deposit box.

    Copies of advance directives often are not transferred from nursing homes to hospitals on admission. One study found that physicians documented advance directives or discussions with appointed proxies about treatment decisions in only 11 percent of admission notes. While 90 percent of Americans say they want to die at home, four out of five die in a hospital or other healthcare facility.

    If you wish to have control over your own end-of-life decisions, you will need to discuss your preferences with your family and physician, complete the documentation, and make sure, on your own or through a representative, that the documentation is included in your medical record at hospitals or other care facilities you enter.

    Leave with a Map

    Before it is time to leave the hospital, be sure you have a realistic plan for your care. Will you be able to care for yourself at home? Will you be able to get along with the help of an available family member? Will you need a visiting nurse or aide? Meals On Wheels? A nursing home? Make contact early, even before you enter a hospital if possible, with a hospital social worker and with other community social service agencies you are familiar with.

    You will also need to make sure that there is a plan for your medical care and management by a physician after you leave the hospital. Will you turn to your primary care doctor or to a specialist who treated you in the hospital? If a doctor other than the doctor who managed your care in the hospital will be responsible, you will need to take steps to ensure that the doctor who will be taking over has full information about you and your case right away.

    That kind of information is supposed to be contained in a well-organized and thorough "discharge summary," which is supposed to be communicated promptly to the doctor who will be caring for you. Unfortunately, it doesn't always work that way.

    Discharge summaries often are in a relatively unstructured, narrative format that invites inaccuracies. In addition, there can be significant delays transmitting discharge summaries to the doctors who need them.

    In one study examining the effectiveness of inpatient follow-up care, nearly ten percent of discharged patients experienced worsening of symptoms or functional capacity as a result of an inadequately managed discharge process. Another study demonstrated that patients may be less likely to be readmitted to the hospital if their primary care provider receives a discharge summary. Yet one study found that only 34 percent of patients had a discharge summary sent to their outpatient care provider.

    Be active in planning the care you will receive after discharge. Before leaving the hospital, ask your doctor when a discharge summary will be prepared, to whom it will be sent, and how it will be sent. Ask that a copy be sent to you. Then keep track of whether you get one and check with your outpatient care provider to be sure that provider's copy arrived.

    Be Aware of Your Rights and Complain Where Necessary

    If you feel you are not being treated with the proper respect or care, talk with the staff concerned. If that fails, talk with the nurse who works on the floor most regularly or with the head nurse on the floor. You can also check whether the hospital has a patient representative or ombudsman department. You can call a patient representative to talk about anything from cold food to rude staff. This person is charged with taking the problem to the responsible department and checking back with you to ensure that the problem is corrected.

    To help you insist on the care you deserve, it is useful to know your rights as a patient. Every hospital should have a statement of patient rights. You might ask for a copy of this statement at the time of admission or before. It should cover such matters as the right to informed consent and participation in your medical care, the right to privacy during physical examination, and the right to refuse to participate in any hospital research experiments.

    To help you insist on the care you deserve, it is useful to know your rights as a patient. Every hospital should have a statement of patient rights. You might ask for a copy of this statement at the time of admission or before. It should cover such matters as the right to informed consent and participation in your medical care, the right to privacy during physical examination, and the right to refuse to participate in any hospital research experiments.

    Don't Let Yourself Be Dumped

    Because hospitals are paid by the case by Medicare and in a similar fashion by some other insurance plans, a hospital may come out better financially by discharging patients prematurely. Don't let this happen to you. First, tell your doctor that you don't feel well enough to go home. If he or she can't or won't stop the discharge process and if you are on Medicare, the hospital is required to give you a written description of an appeal procedure. During your appeal, which usually takes a day or two, you can stay in the hospital.


    Keeping Costs Down

    Most consumers care much more about a hospital's quality than about its prices. That's because under many insurance policies, your hospital bills will be paid in full even at the most expensive of hospitals.

    But if your policy is less generous—for example, requiring you to pay 20 percent of hospital costs—your share of the differences in hospitals' charges can be significant—amounting to thousands of dollars in some cases.

    You can call hospitals to inquire about charges for a private room or semi-private room and other basic services, and you can ask about typical charges for your type of case. Also, check whether an agency in your state regularly publishes comparisons of charges.

    Whatever hospital you choose, there are various ways to keep costs down. For example—

    • Ask your doctor if you can have any needed tests—complete blood count, urinalysis, etc.—done by an outside lab or as a hospital outpatient before you are admitted to a hospital. You save by finding a less expensive lab and by avoiding a day or more in the hospital. Also, check whether every test the hospital wants to give you at entry is necessary and has been ordered by your doctor. Your health insurance may not reimburse for tests routinely done on admission unless specifically ordered.
    • Ask your doctor if a hospital is the only place where your treatment can be done. Perhaps several visits to a hospital or a clinic as an outpatient will do just as well. If surgery is planned, check whether it is one of the many procedures now being performed on an outpatient basis.
    • Check in late and check out early. Hospitals work like hotels; there is a time when the admission day begins and ends. Find out when it is. If you can come in the same day as your procedure, you will not have to pay to sit around. Short hospital stays are becoming more common. Ask your doctor if you can go home as soon as you feel like it. Many people feel better resting at home anyway.
    • If your recuperation is likely to be long and you still require nursing assistance, find out about home health services. Care in your home is often much less expensive than prolonged hospital care, and may be more convenient for your family. Your doctor or the hospital's patient representative or social services department can help you get care at home. Medicare and most insurance plans will cover some portion of the costs of this kind of care if you have been in the hospital and the doctor recommends it.
    • If you need blood transfusions, find out whether you can be your own donor. If surgery is planned several weeks away, you may be able to give a few units, which will replace themselves before the surgery. Find out if you can donate for yourself or have friends and family donate for you.
    • If your health insurance plan requires that you get authorization from it before hospital admission in non-emergency cases and shortly after admission in emergency cases, be sure to get these authorizations so you won't be stuck with the bill. Also, be sure to find out whether a second opinion is required before admission.
    • Check your bill. Be sure you aren't being charged by a hospital for more days than you were there. Also, check that you're only charged for medications you actually received and for tests and x-rays that actually took place. If a planned series of tests was canceled, be sure the charges didn't make it onto your bill.
    • Don't pay twice. If a hospital's staff does a test or x-ray improperly or misplaces the results, be sure you are not billed for the retests.

    Resources for Doing Your Own Medical Research

    Asking doctors questions is one way to learn about your medical condition. But you'll learn more—and have a better opportunity to grasp the information at your own pace—if you also seek out online or printed information. There are many sources of this kind of information, including the following online resources—

    Healthfinder
    A free gateway to reliable consumer health and human services information developed by the U.S. Department of Health and Human Services.

    Mayo Clinic
    General-information website with Mayo's advice and information, including such features as "Diseases and Conditions A-Z," "Condition Centers," "Healthy Living," and "Health Tools."

    MedlinePlus
    A consumer-oriented website that brings together authoritative information from the U.S. National Library of Medicine, the National Institutes of Health, and other government agencies and health-related organizations. Includes extensive information about drugs, an illustrated medical encyclopedia, interactive patient tutorials, and recent health news.

    PubMed
    A service of the U.S. National Library of Medicine that includes over 17 million citations from academic journals for biomedical articles dating back to the 1950s. Includes links to many abstracts, full text articles, and other related resources.

    National Guideline Clearninghouse
    A resource sponsored by the Agency for Healthcare Research and Quality that gives information on current guidelines for the diagnosis and treatment of diseases.

    Merck Manuals Online Medical Library
    Includes the "Merck Manuals Home Edition," which explains disorders, who is likely to get them, their symptoms, how they're diagnosed, how they might be prevented, how they can be treated, and prognoses. Also includes the "Merck Manual of Health and Aging" and other resources.

    University of Pittsburgh Medical Center-Managing Your Health
    Consumer-oriented website with information on conditions and diseases, procedures, and drugs. Includes an "anatomy navigator," health tools and calculators, a medical dictionary, and other resources.

    As an alternative to these online resources, patients can use available libraries. At any major public library, you can ask for general consumer-oriented medical literature or for medical texts. For more in-depth information, you can use a medical school library. These libraries may also be able to help patients find support groups and organizations that regularly provide information on the patient's type of medical problem.

    Special Considerations for Cancer Cases

    The types of cases used in our calculation of risk-adjusted death rates did not include cases in which cancer was the diagnosis listed as the primary reason for hospital admission. Calculating risk-adjusted death rates is not as meaningful for cancer cases as for many other types of cases. Often, what the hospital does can have little or no effect on whether the patient dies within 30 days after hospital admission, which is the period for which the hospital death rates were calculated. The death from cancer may be unavoidable, and the hospital's efforts may be focused on pain reduction or treatment of secondary problems. Some hospitals may have a higher proportion of advanced cancer cases than other hospitals have, depending in part on community customs and resources for treating such cases in nursing homes, hospices, or other settings.

    Nonetheless, it is important to choose a top-quality institution for the treatment of cancer, whether inpatient or outpatient. Choice of such an institution might have a big effect on the long-term outcome.

    One indication of an institution's competence in the treatment of cancer is designation by the National Cancer Institute (NCI) as a Comprehensive Cancer Center or a Clinical Cancer Center. This designation is given to major academic and research institutions throughout the United States with broad-based, coordinated, interdisciplinary programs in cancer research. These institutions have been selected by the NCI for scientific excellence and capability to integrate a diversity of research approaches to focus on the problem of cancer. In addition to doing research, the institutions also treat patients.

    A further indication of an institution's competence in treating cancer is membership in the National Comprehensive Cancer Network (NCCN). NCCN is a not-for-profit alliance of leading cancer centers. It seeks to help member institutions to do excellent research, measure the outcomes of the care they provide, and provide state-of-the-art cancer care to as many patients as possible.

    The following is a list of NCI-designated Comprehensive and Clinical Cancer Centers and NCCN network members, as of March 2012. Bear in mind that there are many other high-quality institutions that might be more convenient for you, but you or your physician might want to seek advice or referrals from professionals at the listed institutions.

    StateName of the CenterCity
    ALUAB HospitalBirmingham
    AZUniversity Medical CenterTucson
    CACity of HopeDuarte
    CARonald Reagan UCLA Medical CenterLos Angeles
    CAScripps Green HospitalLa Jolla
    CAScripps Memorial Hospital La JollaLa Jolla
    CAStanford University Medical CenterStanford
    CAUC Davis Health SystemSacramento
    CAUCSD Thornton HospitalLa Jolla
    CAUCSF Medical Center at Mount ZionSan Francisco
    CAUCSF Medical Center at ParnassusSan Francisco
    CAUniversity of California Irvine Medical CenterOrange
    CAUSC Norris Comprehensive Cancer CenterLos Angeles
    COUniversity of Colorado HospitalAurora
    CTYale-New Haven HospitalNew Haven
    DCGeorgetown University HospitalWashington
    FLH. Lee Moffitt Cancer Center & Research InstituteTampa
    GAEmory University HospitalAtlanta
    IAUniversity of Iowa Hospitals & ClinicsIowa City
    ILNorthwestern Memorial HospitalChicago
    ILUniversity of Chicago Medical CenterChicago
    INIndiana University HospitalIndianapolis
    MADana-Farber Cancer InstituteBoston
    MDThe Johns Hopkins HospitalBaltimore
    MDUniversity of Maryland Medical CenterBaltimore
    MEMount Desert Island HospitalBar Harbor
    MIKarmanos Cancer CenterDetroit
    MIUniversity Hospital/C.S. Mott Children's Hospital/Von Voigtlander Women's HospitalAnn Arbor
    MNRochester Methodist HospitalRochester
    MNSt. Marys HospitalRochester
    MNUniversity of Minnesota Medical Center, Fairview--East BankMinneapolis
    MOBarnes-Jewish HospitalSt Louis
    NCDuke University HospitalDurham
    NCUniversity of North Carolina HospitalChapel Hill
    NCWake Forest Baptist Medical CenterWinston-Salem
    NEThe Nebraska Medical CenterOmaha
    NHMary Hitchcock Memorial HospitalLebanon
    NJRobert Wood Johnson University HospitalNew Brunswick
    NMUniversity of New Mexico HospitalAlbuquerque
    NYJacobi Medical CenterBronx
    NYMemorial Sloan-Kettering Cancer CenterNew York
    NYNew York-Presbyterian HospitalNew York
    NYNYU Langone Medical CenterNew York
    NYRoswell Park Cancer InstituteBuffalo
    OHOhio State's James Cancer Hospital & Solove Research InstituteColumbus
    OHUniversity Hospitals Case Medical CenterCleveland
    OROHSU Hospital & ClinicsPortland
    PAFox Chase Cancer CenterPhiladelphia
    PAHospital of the University of PennsylvaniaPhiladelphia
    PAThomas Jefferson University HospitalPhiladelphia
    PAUPMC ShadysidePittsburgh
    SCMUSC Medical CenterCharleston
    TNSt. Jude Children's Research HospitalMemphis
    TNVanderbilt University Medical CenterNashville
    TXThe University of Texas M. D. Anderson Cancer CenterHouston
    TXUniversity HospitalSan Antonio
    TXUT Southwestern University Hospital St. PaulDallas
    UTUniversity Health Care--University of UtahSalt Lake City
    VAUniversity Health SystemCharlottesville
    VAVCU Medical CenterRichmond
    WAFred Hutchinson Cancer Research CenterSeattle
    WIUW Hosptial & ClinicsMadison

    Hospitals Recognized for Excellence in Nursing Services

    Another indicator of hospital quality, not shown on our Ratings Tables, is recognition of a hospital by the Magnet Recognition Program, which was developed by the American Nurses Credentialing Center to identify healthcare organizations that provide the best in nursing care. At the time of this writing, nearly 400 acute-care hospitals had attained this recognition. We have found that these hospitals also have significantly lower risk-adjusted mortality rates than other hospitals in our "all cases" category, and they were rated much higher than other hospitals by the physicians we surveyed.

    For more information on this program, and to obtain a current list of hospitals that have been recognized by this program, visit www.nursecredentialing.org.


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