The Relationship Between Magnet� Hospitals and Nurse-Driven Patient Outcomes
Repository Posting Date2017-07-19T20:55:00Z
Author(s)Joseph, Amelia M.
Author DetailsAmelia M. Joseph, PhD, MBA, RN
Lead Author Sigma AffliationAlpha Xi
Level of EvidenceN/A
Purpose: Magnet® hospitals were established as a standardized program in 1990 by the American Nurses Credentialing Center to allow hospitals to be designated as excellent places for nurses to practice. Hospitals with this designation have the reputation of improved nurse-driven patient outcomes due to the structures and processes that support the organizational culture. However, the evidence does not conclusively support the effect that this designation has on patient outcomes. The aim of this study was to use publically available Medicare data to compare nurse-driven patient outcomes in Magnet® hospitals versus non- Magnet® hospitals across the United States.
The term “magnet” was first applied to hospitals following a 1983 study commissioned by the American Academy for Nursing to determine why certain hospitals easily hired and retained nurses. Forty-one hospitals were found to have specific characteristics that were especially attractive to nurses which created the idea of Magnet® hospitals (McClure, Poulin et al. 1983). In December, 1990, the American Nurses Association Board of Directors established the Magnet® Hospital Recognition Program which designated specific hospitals that demonstrated a work environment that encouraged and rewarded professional nursing. The first hospital was named in 1994. The program was renamed in 2002 to the Magnet® Recognition Program and is directed by a nine member, voluntary governing body made up of representatives from national nursing organizations as well as nurse managers and direct care nurses (Morgan, Lahman et al. 2006). Designation of Magnet® status is voluntary for hospitals and involves a multifaceted, peer review evaluation system. Final determination is made by the governing body. Designation is conferred for four years at which time, the facility must re-apply and undergo the same rigorous review. In the past five years, the standards have focused more on outcomes than on structure and process (Morgan, Lahman et al. 2006, Goode, Blegen et al. 2011).
The evidence for the effect that this designation has on patient outcomes is mixed. A multi-site study using the Agency for Healthcare Quality and Research (AHRQ) data among 60 Magnet®, 720 non-Magnet®, and 19 Magnet® aspiring hospitals found a lower incidence of central nervous system disorders, hospital acquired pneumonia, and hospital acquired urinary tract infections in Magnet® hospitals when compared to non-Magnet® hospitals. Magnet® aspiring hospitals also had a lower incidence of central nervous disorders and hospital acquired pressure ulcers than non-Magnet®. However, non-Magnet® facilities had lower incidence of deep vein thrombosis/pulmonary embolism, failure-to-rescue, and pulmonary complications. There was no difference among the three groups for mortality, sepsis or surgical infections (Carlson 2009). Goode and colleagues used University Hospital Consortium data to measure patient outcomes in 19 Magnet® and 35 non-Magnet® hospitals based on patient safety indicator software published by AHRQ. Non-Magnet® hospitals had better outcomes for infections, post-operative sepsis, and postoperative metabolic derangement. Only pressure ulcers showed a lower incidence in Magnet® hospitals (Goode, Blegen et al. 2011). Among surgical patients treated in Magnet® hospitals, 7.7 percent were less likely to die within 30 days and 8.6 percent were less likely to die after a postoperative complication than in non-Magnet® hospitals (Friese, Rong et al. 2015). Among emerging Magnet® hospitals, 30-day mortality decreased by 2.4 fewer deaths per 1000 patients during an 8 year period. Failure-to-rescue decreased by 6.1 fewer deaths per 1000 patients during the same period (Kutney-Lee, Stimpfel et al. 2015). Using AHRQ Cost and Utilization data, no significant difference were found between Magnet® and non-Magnet® hospitals among pressure ulcers and failure to rescue (Mills and Gillespie 2013).
A systematic review of studies of patient outcomes among Magnet® hospitals found that the evidence for the effect of Magnet® designation on patient outcomes is inconclusive. Among the 141 studies that were screened, only ten met the inclusion criteria. This small sample was due to the methodological heterogeneity and poor quality design of studies. The sample was too small to allow for any strong conclusions to be reached by the investigators (Daniel and Regnaux 2015).
This is a retrospective, descriptive study using three different data sources. The first data source is from the Centers for Medicare and Medicaid (CMS) web-site using hospital compare data. These data are the results of the efforts of the Hospital Quality Alliance in collaboration with CMS. A variety of different data sets are available for use. For the purposes of this study, data on hospital acquired infections and hospital acquired conditions were selected. Only variables thought to be sensitive to nursing care were considered using indicators established by the National Quality Forum (Naylor, Volpe et al. 2013). Catheter associated urinary tract infections (CAUTI) and central line blood stream infection (CLAB) were selected from the data set on hospital acquired infections and are reported over a 24 month time period, July, 2009 through June, 2011. Pressure ulcers, falls, and glycemic control were selected from the hospital acquired conditions set and are reported over the same time frame. Hospitals that did not report data for all of the five selected variables were excluded. The final sample contained data from 2780 hospitals.
The second is a list of Magnet® designated hospitals which was obtained from the American Nurses Credentialing Center (ANCC) web site. The ANCC is the arm of the ANA that administers the Magnet® Program. Three hundred fifty-eight hospital names were downloaded. These were then matched with data from the Medicare Compare web-site. Children’s hospitals were excluded as were any hospital which was obviously a specialty care hospital based on the name (orthopedics, spine, eye, etc.). International hospital and hospitals with the Department of Veterans Affairs were excluded as they do not accept Medicare assignment and are not required to report data to Medicare. Critical Access Hospitals were also excluded as they are exempt from reporting data. Some hospitals could not be matched to hospitals in the Medicare data set by name or address and these were excluded leaving a total of 290 Magnet® hospitals.
The final data set that was used was data from the American Hospital Association web-site which provided information on the type of hospital ownership: private (voluntary private church based (VOLNPCHU); voluntary private (VOLNPPRI); voluntary private other (VOLNPOTH), public: federal government (GOVFED); hospital district (GOVHOSDIS); local (GOVLOC); or state (GOVST), or proprietary (PROP). Hospitals were also classified into geographic region as follows: New England (NE); mid-Atlantic (MA); Atlantic-south (AS); deep south (DP); great plains (GP); great lakes (GL); Rocky Mountains (RM); southwest (SW); and Pacific area (PA).
The dependent variable is Magnet® hospital status which is defined as any hospital that is listed on the ANCC web site.
The independent variables are:
Central line associated blood stream infection (CLAB) which is measured in number of infections per 100 discharges;
Catheter associated urinary tract infections (CAUTI) which is measured in number of infections per 100 discharges;
Glycemic control (BS) which is blood glucose greater than 180 mg/Dl per 100 discharges;
Hospital acquired pressure ulcers (PU) is the incidence of severe (stage 3 or 4) pressure ulcers per 100 discharges;
Falls are an unanticipated contact with the floor per 100 discharges.
Descriptive analysis was done on the full data set. As each variable performs independently of the others, that is the possibility of developing a pressure ulcer is not related to experiencing a fall, t-tests were used to compare the mean scores of Magnet® versus non-Magnet® hospitals for each variable.
Ten percent of the 2780 hospitals that were reviewed held Magnet® designation at the time of the study. The Great Lakes region had the most designated hospitals. The overwhelming majority of designated hospitals fell into a voluntary ownership status at 82.7%.
There was no significant difference between the rates of pressure ulcers and glycemic control between Magnet® and non-Magnet® hospitals. Rates of CAUTI and CLAB were found to be better in non-Magnet® hospitals. Only the rate of falls was significantly better among Magnet® hospitals.
The evidence to support improved patient outcomes in Magnet® hospitals is inconsistent. This most recent study adds little to our knowledge. Glycemic control has not previously been reported in the literature related to Magnet® designation and findings from this study do not support a relationship. Although lower hospital acquired pressure ulcer rates have been reported in Magnet® hospitals (Mills 2008, Goode, Blegen et al. 2011), this association could not be confirmed. Evidence of a lower rate of hospital acquired urinary tract infections in Magnet® hospitals could neither be confirmed or denied as this measure is not the same as catheter associated urinary tract infections which was the variable that was used in this study. Only the findings for falls were consistent with the published literature (Lake, Shang et al. 2010).