Ask any nurse from a Magnet-recognized hospital if their facility is better than a non-Magnet counterpart and you’ll get a quick yes. There are even some studies that seem to back up these strictly from-the-gut responses. But those previous studies have looked at Medicare discharges, neonatal patients, and surgical patients. None has examined patient outcomes at Magnet facilities — over 400 as of March 2015 — compared to others over time.
A new Health Affairs study has done just that and, for the first time, found that those facilities do, indeed, have lower mortality and failure-to-rescue rates than other hospitals.1 Magnet hospitals subscribe to several key principles, including transformational leadership, empowering staff, and robust quality improvement mechanisms. More information is available at http://www.nursecredentialing.org/Magnet.
The study looked at nearly 1.9 million patients in almost 1,000 hospitals. Each Magnet facility was paired with two non-Magnet hospitals. The authors looked for 30 day all-cause mortality, as well as failure to rescue, which is defined as one of nine post-operative complications:
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Pulmonary failure
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Pneumonia
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Myocardial infarction
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Venous thromboembolism
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Acute renal failure
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Hemorrhage
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Surgical site infection
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Gastrointestinal bleed
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Reoperation1
The authors contend that failure to rescue is a good quality of care measure because it focuses less “on the occurrence of a complication and more on the hospital’s capability to recognize and address a complication…[and] that, compared to complication rates, failure-to-rescue rates are more closely associated with differences in hospital characteristics.”1
Most Magnet hospitals are larger than their counterparts, and better staffed with more registered nurses per patient day. They were more likely to have transplant programs and be teaching hospitals as well, but less likely to be urban.
The study found that 30-day mortality rates and failure-to-rescue rates were both significantly lower in Magnet facilities than in their matched controls. Patients in Magnet hospitals were 7.7% less likely to experience 30-day mortality (rates of 5.8% versus 6.3%), and Magnet patients were 8.6% less likely to die after a failure to rescue event.1
The authors didn’t find that there was a significant improvement in hospitals after they became Magnet facilities, nor was there a big difference in the year before they gained that status.1
Failure to rescue, which the team used instead of looking at complications, has been studied since 1992, says Christopher R. Friese, PhD, RN, AOCN, FAAN, lead author and an assistant professor at the University of Michigan School of Nursing’s Department of Systems, Populations, and Leadership in Ann Arbor. “It’s endorsed by the National Quality Forum and the premise is that since patients come to the hospital sick, we might not be able to prevent every single complication. However, if we examine patients who develop treatable complications, we can then determine if they died from the complication, or whether the hospital or provider rescued the patient from that complication.”
Friese’s own work, as well as that of two of his coauthors, Jeffrey Silber, MD, and Amir Ghaferi, MD, has demonstrated repeatedly that variations in failure-to-rescue rates are more attributable to differences in hospitals than anything else, while complications, on the other hand, are more attributable to patients’ baseline frailty. This makes looking at that metric something valuable to do, and not just in terms of this study, but in general.
“To measure hospital quality, a lot of us prefer to use failure to rescue rather than surgical complication rates,” he says, noting that there are big debates happening in some forums about the validity of surgical complication rates as a quality measure.
This doesn’t mean that mortality and complication rates aren’t good. But those are “low-hanging fruit” that payers are focusing on right now, he says. “If people think that these endorsed measures will factor into payer decision-making, they should try to identify how best to rescue patients after postoperative complications. Careful review of 30-day mortality after surgery is a good place to start. Why are patients dying? Can those complications be prevented? How can we need to redesign care to rapidly identify and treat complications?”
Friese acknowledges that not every hospital aspires to be, or can be, a Magnet hospital. It is a financial commitment, as well as one of time and manpower, just to go through the application process. “I think the message, though, is to keep looking for ways to improve quality,” he says. “We don’t have a magic bullet yet. Our study found that Magnet hospitals out-performed their peers, but Magnets were better before they were recognized and their performance didn’t improve after they were recognized.”
The fact that there was no post-status improvement in outcomes was a disappointment to him, he says. “Nurses who have participated in the recognition process often call it transformative for their nursing practice. Deep down, I had hoped we’d see further improvements in patient outcomes. It also appears that non-Magnet hospitals are catching up to their peers’ outcome rates over the study’s 13-year period. We’ll have to see if that trend continues.”
The authors are also interested in looking at how hospitals are able to detect complications before they become deadly, he says. “Are nurses and other providers empowered to alert doctors to worrisome signs and get the right resources in place to rescue patients successfully? Is it better ICU care? We’re looking at this right now.”
He says that if he was a leader in a struggling hospital, he would reach out to colleagues that had better outcomes and ask what’s working where they are. “Michigan, we’ve seen remarkable results with the Blue Cross Blue Shield of Michigan-supported quality improvement collaboratives. Hospitals and doctors contribute outcomes data that are analyzed centrally — and confidentially — and best practices can be disseminated quickly. Researchers have shown this approach has reduced mortality and lowered costs in Michigan hospitals for general surgery.”
In addition, the fact that hospitals were doing about the same before and after Magnet status means that there is something about them in and of themselves — something that perhaps makes that kind of hospital attempt and achieve Magnet status, he says. “We are recommending we take a look under the hoods of well-performing hospitals. Many of them are Magnets. Then we can learn what they’re doing differently and share those lessons with struggling hospitals.”
What is known about Magnets, Friese concludes, is that they are better places for nurses to work; they have less bureaucracy within the nursing department; they have better nurse staffing; and they hire more nurses with BSN degrees. “They perform benchmarking on key outcomes, like pressure ulcers and falls,” he says, “and there is some evidence they are more cost-efficient. But we don’t know the mechanisms that improve outcomes. And until we find that out, we’re just guessing.”
For more information on this topic, contact Christopher R. Friese, PhD, RN, AOCN, FAAN, Assistant Professor, University of Michigan School of Nursing, Department of Systems, Populations, and Leadership, Ann Arbor, MI. Email: [email protected]
More information on what it takes to become a Magnet facility are available at http://www.nursecredentialing.org/Magnet
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Friese CR, Xia R, Ghaferi A, Birkmeyer JD, Banerjee M. Hospitals In ‘Magnet’ Program Show Better Patient Outcomes On Mortality Measures Compared To Non-‘Magnet’ Hospitals. Health Aff June 2015 vol. 34 no. 6 986-992
