What do the top hospitals on the Lown Index have in common?

What makes a hospital the “best?”

When we think about hospital performance, the first thing that comes to mind is usually patient outcomes. We expect the best hospitals to save patients’ lives and keep them healthy.

But hospitals do much more than care for individual patients; the decisions that hospitals make have a significant impact on community health and equity. Hospitals are often the largest employers in many communities, but some don’t pay their staff a living wage. Other hospitals have expanded their financial aid programs, helping to make health care accessible for all.

While most hospital rankings only include metrics for patient outcomes, the Lown ranking also takes into account hospitals’ community health investments, pay equity, inclusivity, and avoidance of low-value care. In recognition of the importance of patient outcomes, this category makes up the largest percentage of the grade (50%). Civic leadership gets a weight of 30%, and value of care the final 20%.

Which types of hospitals come out on top?

With this novel ranking, we were interested to see which hospitals would come out on top. Would it be the large teaching hospitals with big reputations, that usually win accolades from US News and other rankings? Or would it be the unsung heroes—the safety net hospitals and public hospitals that take in all patients that come through their doors?

The answer is… a little of both. In our examination of the Top 100 hospitals on the Lown Index, we found that the types of hospitals that do well on other rankings (large, urban teaching hospitals) were more likely to be on the Lown Index Top 100 (see Tables 1a&b), although many of the “big names” found on other rankings did not make it into our Top 100. At the same time,  many safety net hospitals, public hospitals, and small rural hospitals also appear at the top of our list.

Table 1a: Hospital types overrepresented on Top 100 list

Table 1b: Hospital types underrepresented on Top 100 List

Why are larger, urban, teaching hospitals overrepresented on the Lown Top 100 list? Part of the answer is that large teaching hospitals have been found to provide better care for common conditions and have lower rates of patient mortality compared to smaller non-teaching hospitals. Patient outcomes receive more weight in our final ranking than the other two categories in the Lown Index, and this gives large teaching hospitals a boost.

Smaller non-teaching hospitals do slightly better on the Lown Index for civic leadership and much better for value of care compared to large teaching hospitals, but not high enough, it seems, to make up for the difference in patient outcomes (see Table 2).

A similar pattern exists with safety net vs non-safety net hospitals. Safety net hospitals serve a larger proportion of patients who are eligible for both Medicare and Medicaid, giving them high marks for inclusivity. Their executives also receive compensation that’s closer to the wages of their average workers. Caring for a larger proportion of poor, less educated, and non-white patients boosts safety net hospitals’ civic leadership scores, but their overall patient outcomes ranking brings down their total score.

The outcomes scores for safety net hospitals might be lower because they have fewer resources to devote to hiring the best doctors, providing clinician training, and initiating quality improvement programs. But safety net hospitals also care for patients with more acute cases of diseases and more chronic conditions, and these patients are often discharged from the hospital into situations where they are less able to get the continuing care they need. A patient who is discharged to an apartment on the fifth floor of a walk up with no grocery store nearby might not do as well as a patient who can hire an aide to help them recover at home. While our clinical outcomes metrics adjust for underlying patient risk, some of these environmental factors and patient conditions may not be accounted for. That means hospitals caring for the poorest and sickest patients may appear to do worse on patient outcomes than is actually the case.

Table 2: Large teaching hospitals vs small non-teaching hospitals in the Lown Index

But even though larger hospitals, teaching hospitals, and urban hospitals were more likely to be in the Lown Index Top 100 hospitals, there were many exceptions. Several public safety net hospitals came out on top, as did many small hospitals and rural hospitals (see Table 3). A few of these standouts include:

• JPS Health Network, a large public safety net hospital in Fort Worth, TX, which snagged the #1 spot on the Lown Index this year with rankings in the 80th percentile or higher in clinical outcomes, community benefit, inclusivity, and avoiding overuse; 
• Saint Joseph Hospital in Mount Sterling, KY, a rural hospital that has only 42 beds but scored in the top 30% of every category;
• Boston Medical Center in Boston, MA, a safety net hospital that placed far above the Boston hospitals that usually dominate the US News rankings, with particularly high rankings in community benefit, inclusivity, and avoiding overuse.  
• Cortland Regional Medical Center in Cortland, NY, a rural safety net hospital with particularly high scores in clinical outcomes, patient safety, and community benefit.

Table 3: Public, safety net, and small rural hospitals on the Top 100 list