Tuesday, January 17, 2012

De-Magnetizing

One study does not a trend make, but this one has conclusions that are so direct that it is bound to attract lots of attention . . . and anger from certain quarters.  This post, likewise, may prompt additional anger from some of my readers.

C.J. Goode and others have published an article in the Journal of Nursing Administration entitled, "Comparison of patient outcomes in Magnet® and non-Magnet hospitals."  You can view the abstract here.  Let me give you the highlights: 

Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals.

What an indictment of a certification process that the American Nurses Credentialing Center describes as follows: 

The Magnet Recognition Program® recognizes healthcare organizations for quality patient care, nursing excellence and innovations in professional nursing practice. Consumers rely on Magnet designation as the ultimate credential for high quality nursing. Developed by the American Nurses Credentialing Center (ANCC), Magnet is the leading source of successful nursing practices and strategies worldwide.

What is the ANCC? It claims to be "the world's largest and most prestigious nurse credentialing organization." Its website explains: 

The American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association (ANA), provides individuals and organizations throughout the nursing profession with the resources they need to achieve practice excellence.

For purposes of this post, let's accept that and stay away from credentialing and professional advancement programs for individual nurses and focus on what it takes to receive Magnet® designation. Well, like other types of certification programs in other industries, your organization needs to meet an array of standards based on certain philosophical underpinnings, and you need to "pass" a review by independent surveyors.

You also need to pay a lot of money.  There is an application fee, an appraisal fee, a documentation review fee, a site visit fee, and an extension fee if you want to postpone your site visit.  In all, the process costs tens of thousands of dollars, paid to the ANCC, not to mention the costs incurred by the hospital on internal organizational matters.

So, here's the question:  With all that it takes to receive Magnet® status, and with all the assertions by the ANCC about the superior nature of Magnetized institutions, what peer-reviewed data exist that support the assertion that such hospitals do in fact deliver higher quality patient care than the non-Magnetic hospitals?  We now have one such study that indicates the contrary.

Currently, there are 391 Magnet hospitals.  As I look through the list of those from my own state of Massachusetts, I don't see any that offer sufficient public, real-time data about clinical quality to prove the case of higher quality.  And given the dearth of transparency with regard to clinical outcomes nationwide, it is hard to believe that one could do so in any other state.

I did a Google search on the topic of "quality of care at Magnet hospitals" and found very little.  There was a 2010 thesis by Kelly Scott, a nursing student at the University of Kansas, entitled "Magnet Status: Implications for Quality of Patient Care," Magnet Status: Implications for Quality of Patient Care which said: 

In summary, this study did not find evidence to support the expectation that Magnet accreditation directly correlates to lower rates of hospital‐acquired infections. There was evidence to support existing research indicating that nursing workforce characteristics are better in Magnet hospitals. While Magnet accreditation remains the gold standard for nursing work environments, this status does not automatically lead to better patient outcomes. 

And in the absence of real data, it seems that a hospital's enthusiasm for the importance of this status can be transitory, at best: 

Magnet hospital status was "the ultimate benchmark to measure the quality of care" for the University of Kentucky until it failed to get renewal of the designation.

A hospital official questioned its importance last week. "It is a recognition from a professional society," said Dr. Richard Lofgren, chief clinical officer for UKHealthcare. "You can get recognition from a whole lot of professional societies."

Uh oh, it sounds like a lot of revenue for the ANCC might be at risk unless peer-reviewed articles emerge that document real quality improvement results from this certification process.

Read more here: http://www.kentucky.com/2011/03/07/1660635/nursing-care-designation-doesnt.html#storylink=cpy

7 comments:

Anonymous said...

What you wrote is important. When I need medical care I want to see a hospital's run charts on readmissions or falls on their website rather than a big shiny Magnet sign on the front of the building. I know which action speaks more to the beliefs and values of the team I'm entrusting with my health.

Anonymous said...

This post demonstrates, yet again, the general principle that seemingly intuitively obvious conclusions about health care - be they clinical conclusions or quality- or policy-related - are entirely unreliable. If an organization is going to make a statement such as the one below:

"The Magnet Recognition Program® recognizes healthcare organizations for quality patient care..."

the statement must be backed up by real data, or it cannot be construed as anything but advertising. The FDA has penalized drug companies for making such unsupported claims.
I am told this program has existed for over a decade. Should the hospitals now ask for their money back?

nonlocal

Peter Logue said...

You raise this question:

"With all that it takes to receive Magnet® status, and with all the assertions by the ANCC about the superior nature of Magnetized institutions, what peer-reviewed data exist that support the assertion that such hospitals do in fact deliver higher quality patient care than the non-Magnetic hospitals?"

Perhaps an even better one would be: "How can an organization that purports to be quality-based, not have "evidence-based" (i.e. Objective) data to support its reason for existing?

And the followup question: Isn't this, in fact, the most basic element of what such a program preaches?

Anonymous said...

In the interest of fairness I suggest actually looking at the data and how it was obtained before declaring it a valid study to base opinions on.

Summary: The research study is problematic on many fronts, not the least of which is that the data set was from 2005 (6 years old); the data set is specific to UHC hospitals (academic medical centers); and there were only 19 Magnet hospitals in the study.

1. The study used data from 2005, 6 years old, and a full three years before the Magnet model was updated in 2008 to include outcomes. The sample size was limited to only 19 Magnet hospitals. This time lag and the scope of the change in the Magnet requirements call into question the relevance of the study for today‟s researchers. While the study shows statistically significant differences (p<0.05) the clinical significance was not addressed.

2. The study methodology selected University Health System Consortium (UHC) hospitals for its data samples. UHC hospitals, the majority being academic medical centers, can be expected to have "better than average‟ patient outcomes and higher staffing hours primarily due to higher patient acuity and complexity (CMI). Additionally, UHC hospitals have likely implemented many of the evidence-based practices that are the hallmarks of Magnet. The study does not identify the extent to which Magnet and non-Magnet hospitals within the UHC are different on the features that statistically differentiate Magnet hospitals from non-Magnet hospitals in the general hospital population.

Over the past six years, there has been a growing body of research showing that Magnet characteristics do impact patient outcomes. This evidence is highlighted on the ANCC website at http://www.nursecredentialing.org/MagnetReferences.aspx

Paul Levy said...

In all fairness, it would also be good to know the author of this comment, but as always, that is your choice.

I'm sorry to say that the web page you cite is, to me, incomprehensible. What does this mean, for example:

"This reference list includes research studies that have investigated the relationship between Magnet Environments and Patient, Nurse, and/or Organizational outcomes. In general, findings have consistently demonstrated an association between Magnet Characteristics and favorable Nurse or Patient outcomes. The most common approaches to measuring Magnet Characteristics have been to include ANCC Magnet-recognized Organizations in the study sample or to administer a version of the Nursing Work Index survey, which was initially developed to characterize a Magnet Environment."

And why does it say this:

"ANCC cannot provide copies of any articles listed here."

James M. O'Brien, Jr., M.D., M.S. said...

In addition to the financial costs of completing the application and review process for this and other such awards, there is a tremendous opportunity cost. I have assisted some of the nursing comittees who spend considerably time completing the application and reveiw process. I wonder what the results might have been had this time been devoted to direct quality improvement. Additionally, if an institutions chooses to prioritize these applications and yet does not appear to provide the same resources and time to direct quality improvement, it sends a clear message to its employees about the true priorities of the organization.

Regarding the issues of the predominant association between such designations and outcome - this would be an easier inference to make if there was a transparent reporting of the data. Ultimately, the costs of these applications must be paid for by health care dollars - therefore, they should have some semblance of cost-effectiveness - with an asessement that includes the man-hour costs of the application and review process.

Anonymous said...

In response to anonymous 0930 and Paul's comment of 0938: I reviewed the reference list provided at the indicated website. Let us clarify the question here: it is, is there peer-reviewed evidence that Magnet hospitals provide higher quality patient care than non-Magnet hospitals?
Reviewing the reference list, there appear to be few articles that address this specific question. Most appear to be related to nurse practice environment or nursing perception of work environment, rather than directly measuring quality of PATIENT care. One cannot use nurse practice environment as a surrogate marker here.

The only article I see that might, even tangentially, address this question is:

Armstrong K, Laschinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009 Jan-Mar;24(1):55-62

It would be interesting if anon 0930 could provide the abstract of this article.

nonlocal MD