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Sustained Hospital Performance on Hospital

Consumer Assessment of Healthcare Providers
and Systems Survey Measures: What Are
the Determinants?
Mona Al-Amin, PhD, interim chair and associate professor, Healthcare Administration, Suffolk
University, Boston, Massachusetts; Melody K. Schiaffino, PhD, assistant professor, Division of Health
Management and Policy, San Diego State University, California; Sinyoung Park, PhD, assistant
professor, Department of Health Administration, University of North Florida, Jacksonville; and
Jeffrey Harman, PhD, professor, Department of Behavioral Sciences & Social Medicine, College of
Medicine, Florida State University, Tallahassee

EXECUTIVE SUMMARY

This study examines hospital characteristics associated with sustained superior performance
on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) mea-
sures. We classified hospitals as sustainers if they remained in the top 25th percentile of
overall patient ratings of inpatient experience from 2009 through 2013. We classified hospital
characteristics as modifiable or unmodifiable. Modifiable characteristics are operational
measures that hospitals can change to improve performance; these characteristics include
registered nurse (RN) staffing levels, presence of hospitalists, and level of physician inte-
gration. Unmodifiable characteristics are core structural dimensions, such as hospital size
and teaching status, that require substantial investment to change, as well as market-level
factors such as competition and unemployment rates. Using logistic regression analysis, we
found that RN staffing levels, Medicare share of inpatient days, teaching status, and market
competition were significant predictors of the likelihood that a given hospital sustained high
levels of patient ratings over time (i.e., the likelihood of a hospital being classified as a sus-
tainer). Hospitals with a higher ratio of inpatient days to RN staffing and higher Medicare
share of inpatient days had lower odds of being classified as sustainers.

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For more information about the concepts in this article, contact Dr. Al-Amin at malamin@suffolk.edu.
The authors declare no conflicts of interest.
© 2018 Foundation of the American College of Healthcare Executives
DOI: 10.1097/JHM-D-16-00006

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© 2018 Foundation of the American College of Healthcare Executives
Journal of Healthcare Management
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INTRODUCTION
With the passage of the Affordable Care
Act in 2010 and the move toward value-
based purchasing (VBP), hospitals have
tried to improve their performance in key
areas such as patient ratings, patient out-
comes and safety, and hospital efficiency.
The continuous financial threat facing
hospitals if they fail to achieve satisfactory
scores on publicly reported measures un-
derscores the importance of determining
the factors associated with sustained per-
formance. Pay-for-performance programs,
which include VBP, subject hospitals to
significant financial loss by placing up to
6% of a hospital’s base operating pay at
risk (Kahn et al., 2015). Therefore, hospi-
tals are under pressure to perform well in
key quality and efficiency dimensions. Al-
though previous research has examined the
relationship between hospital characteris-
tics and patient experiences and outcomes
of care (Lehrman et al., 2010), few studies
have examined sustained superior hospital
performance with regard to patient out-
comes and satisfaction ratings.
In the past few years, measuring, report-
ing, and improving hospital performance
on quality of care became a priority for
policymakers, payers (private and public),
and hospitals (Lehrman et al., 2010). Patient
ratings of inpatient experiences emerged as
a key component of the overall evaluation
of hospital performance for both research
and reimbursement purposes. Al-Amin,
Makarem, and Rosko (2016) stated that “the
traditionally undervalued role of patients in
the evaluation and co-production of health-
care services has finally been recognized”
(p. 297). The Hospital Consumer Assess-
ment of Healthcare Providers and Systems
(HCAHPS) survey was developed by the
16
© 2018 Foundation of the American College of Healthcare Executives
Centers for Medicare & Medicaid Services in
collaboration with the Agency for Healthcare
Research and Quality to evaluate patient expe-
riences, provide information to consumers as
they compare hospitals, and incentivize hospi-
tals to improve the inpatient care experience
(Goldstein Farquhar, Crofton, Darby, &
Garfinkel, 2005). The survey contains 25
questions that assess major domains or aspects
such as nursing care, discharge care, and the
hospital environment (Shwartz, Restuccia, &
Rosen, 2015). Therefore, the HCAHPS survey
provides valuable information about patient-
centered care from the patient’s perspective
(Price et al., 2014).
Hospitals are incentivized to perform
well on the HCAHPS survey through the
availability of patient ratings data to the
public and through VBP. Moreover, pa-
tient ratings might be of interest to hospi-
tals given their association with patient
outcomes. Tsai, Orav, and Jha (2015)
found a positive relationship between high
patient ratings and hospital efficiency and
quality. Elliott et al. (2015) found signifi-
cant improvements in HCAHPS scores
between 2008 and 2011, which might in-
dicate that hospitals are responding to
financial pressures to improve patients’
experiences as well as public reporting of
patient satisfaction ratings.
The aim of this study was to deter-
mine modifiable and unmodifiable hospital
characteristics that predict sustained supe-
rior hospital performance. We classified
hospitals as sustainers if a high percentage
of their patients, compared with other
hospitals, gave the hospital a 9 or 10 rating
(on a 10-point scale) on the HCAHPS
survey over a 5-year period (2009–2013).
The likelihood of a hospital sustaining high
patient ratings over a long period has
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received little, if any, attention in health
services research; rather, investigators have
focused on comparisons between hospi-
tals at a single point in time. However,
conducting a cross-sectional investigation
of the determinants of hospital perfor-
mance on HCAHPS scores is insufficient;
rather, it is important to determine the
factors associated with consistently high
levels of performance over time. The need
for longitudinal studies also applies to in-
vestigations of readmission rates, hospital-
acquired infection rates, and other
quality indicators.
The resource-based view (RBV) of the
firm is a well-established management
theory that argues that, for an organization
to achieve a sustained competitive advan-
tage, it must possess valuable resources and
capabilities that are difficult to replicate
(Barney, 1991; Kraaijenbrink, Spender, &
Groen, 2010). Healthcare organizations, in
general, rely on external environmental
frameworks as they compete in a highly
regulated and changing industry. However,
RBV offers an internal perspective with a
focus on resources that play an important
role in implementing strategy and achiev-
ing organizational goals (Kash, Spaulding,
Gamm, & Johnson, 2014). We relied on the
RBV conceptual framework to investigate
organizational factors associated with a
hospital’s ability to sustain higher patient
ratings than its competitors.
CONCEPTUAL FRAMEWORK
Investigators in healthcare research widely
acknowledge that hospital characteristics
such as staffing levels predict patient out-
comes. These characteristics influence key
dimensions of patient care such as patient-
centeredness, patient monitoring, care
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© 2018 Foundation of the American College of Healthcare Executives
management, and continuity of care
(Vahey, Aiken, Sloane, Clarke, & Vargas,
2004), as well as a hospital’s ability to make
changes that lead to improved patient ex-
periences and outcomes (Al-Amin et al.,
2016). Aiken, Clarke, & Sloane (2002) were
among the first to use the term “modifiable
hospital characteristics” rather than group
all structural dimensions into one category.
Risk factors for diseases such as cancer are
typically classified as modifiable (e.g.,
smoking, diet, physical activity) or
unmodifiable (e.g., genetics; Stein &
Colditz, 2004). People can alter modifiable
factors and thus lower the likelihood of
experiencing negative outcomes. Although
unmodifiable factors are beyond the con-
trol of an individual, identifying them is
also beneficial. For example, unmodifiable
factors can be used for screening purposes.
If we can identify factors in healthcare
organizations that can be modified to im-
prove outcomes, we can provide adminis-
trators with data to help them enhance
performance. Identifying unmodifiable
factors, on the other hand, provides insight
into how performance differs between
hospitals and enables researchers to deter-
mine which hospitals are less likely to sus-
tain high levels of performance and so
potentially could be used to risk-adjust
hospital ratings. Therefore, we investigate
the association between modifiable and
unmodifiable hospital characteristics and
sustained superior performance.
Researchers are interested in deter-
mining organizational characteristics as-
sociated with higher levels of performance
(Keats & Hitt, 1988; Lenz, 1980). However,
research has focused on adaptation and
alignment between the organizational
structure and/or strategy and the
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environment as predictors of performance.
This perspective views organizational per-
formance in terms of market share, vol-
ume, or profitability (Dess & Davis, 1984).
Defining organizational performance is one
of the thorniest issues faced by researchers
(Venkatraman & Ramanujam, 1986). In
healthcare, as reimbursement schemes
evolve around performance measures, re-
searchers also must confront the issue of de-
fining hospital performance. Venkatraman
and Ramanujam (1986) discussed three do-
mains of organizational performance that
capture the predominant classifications in the
literature. These domains range from finan-
cial (e.g., profitability, return on investment)
to financial operations (e.g., quality, techni-
cal efficiency) and, finally, to organizational
effectiveness, the broadest domain. The
Affordable Care Act has shifted the focus on
hospital performance from the financial
domain to the operational and organiza-
tional effectiveness domains, whereby per-
formance is now defined largely as the ability
to manage the health of the population
served rather than the volume of services
provided. While organizational effectiveness
is the ultimate performance domain, we
focus here on one operational performance
measure: patient satisfaction.
To guide our efforts in determining
predictors of sustained hospital perfor-
mance, we relied on its RBV to understand
organizational performance (Barney,
Ketchen, & Wright, 2011). RBV argues that
superior organizational performance is
achieved through the resources used
to produce the service or product
(Wernerfelt, 1984). Barney (1991) ex-
tended the RBV by specifying that rare and
valuable resources are the ones that lead
the organization to superior performance.
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© 2018 Foundation of the American College of Healthcare Executives
We classified assets as physical, intangible,
and personnel related (Grant, 1991).
Physical resources include technology,
equipment, location, and access to raw
materials (Short, Palmer, & Ketchen,
2002). Technologies in healthcare organi-
zations can be classified as informational,
clinical, informational, administrative, and
social (Spaulding, Kash, Johnson, &
Gamm, 2017). Information technologies
include electronic health records (EHRs),
clinical technologies facilitate diagnosis
and treatment, administrative technologies
support business processes (e.g., billing and
scheduling), and social technologies abet
training, support, communication, and
other elements that lead to better provider–
patient relationships. In our model, we
included only clinical and information
technologies because implementation of
EHRs and a high level of physical resources
might contribute to a hospital’s sustained
performance. Intangible assets include
those that influence hospital innovation
and capabilities (Short et al., 2002).
We focused on two intangible assets:
teaching status and level of physician inte-
gration. Teaching status is an intangible
asset because teaching hospitals have an
educational and research-oriented mission.
Lehrman et al. (2010) found that teaching
hospitals were associated with superior
performance in both patient experiences
and outcomes of care. We classified hospi-
tals as fully integrated if they adopted any
of the following arrangements with physi-
cians: integrated salary model, foundation
model, or equity model (Baker, Bundorf, &
Kessler, 2014). In recent years, hospitals
have moved toward arrangements that
ensure the highest levels of integration
(Baker et al., 2014). Hospitals are
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concerned about achieving better patient
ratings and better patient outcomes at a
lower cost. High levels of physician inte-
gration are believed to enable hospitals to
achieve these goals. Therefore, we pre-
dicted that fully integrated hospitals were
more likely to be sustainers. Finally, human
resources, which include staffing levels of
key professionals such as registered nurses
(RNs) and hospitalists, are crucial assets in
the hospital setting. Given the strong evi-
dence supporting an association between
RN staffing levels and patient outcomes,
staffing levels are central to hospital perfor-
mance (Kane, Shamliyan, Mueller, Duval, &
Wilt, 2007). Research findings also indicate
that hospitals in which hospitalists provide
patient care have lower mortality rates (Tsai,
Joynt, Orav, Gawande, & Jha, 2013) and
lower readmission rates (Jungerwirth,
Wheeler, & Paul, 2014). A hospitalist re-
places a patient’s primary care provider
during the inpatient stay (White & Glazier,
2011). Hospitalists’ specialization in hospital
medicine and the hospital setting empowers
them with knowledge of a hospital’s processes
and enhances their ability to coordinate the
care of patients. Therefore, we predicted that
hospitals that adopted the hospitalist model
were more likely to be sustainers. Hospitalists,
RN staffing levels, and the level of physician
integration are factors that hospitals can
modify to improve performance.
Finally, a study of hospital perfor-
mance is incomplete without accounting
for the environment in which the organi-
zation operates. Therefore, in accordance
with industrial organization economics, we
examined the association between compe-
tition and sustained superior performance.
Competition is associated with health system
efficiency (Enthoven & Vorhaus, 1997),
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including lower hospital costs and healthcare
premiums (Enthoven & Singer, 1996) as
well as decreased provision of uncompen-
sated care (Mann, Melnick, Bamezai, &
Zwanziger, 1995).
However, it is not clear if the cost sav-
ings and differences in utilization in com-
petitive markets influence the general quality
of care. Mutter Wong, & Goldfarb (2008)
assessed the relationship between hospital
competition and inpatient quality of care
using 1997 data for all hospital discharges in
22 states. Although their study findings were
inconclusive, they suggested that hospital
competition improves quality of care in mea-
sures that are visible to patients, such as com-
plications from anesthesia, and decreases in
those that are not, such as postoperative com-
plications. However, the literature contains few
studies of the relationship between hospital
competition and patient satisfaction (Kazley,
Ford, Diana, & Menachemi, 2015; Makarem &
Al-Amin, 2014). Greater hospital competition,
as measured by the Herfindahl–Hirschman
Index (HHI), has a positive impact on patient
perceptions of healthcare services (Makarem
& Al-Amin, 2014). Yet, according to Kazley,
Ford, Diana, & Menachemi, (2015), two pa-
tient rating measures from HCAHPS—overall
patient rating of their experience and whether
they would recommend the hospital—were not
significantly associated with changes in com-
petition. The mixed results of the impact of
market competition on patient satisfaction may
be due to the use of different data sets, time
periods, measurements of patient satisfaction,
and conceptual frameworks.
METHODS
The main objective of this study was to
determine modifiable and unmodifiable
organizational characteristics that predict
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sustained hospital performance over a 5-year
period. We collected data for this study from
multiple sources using the hospital as the
unit of analysis. We compiled patient ratings
from the Hospital Compare website through
the HCAHPS survey consisting of panel data
from 2009 through 2013. HCAHPS is a na-
tionally recognized survey used to assess
patients’ self-reported satisfaction with their
hospital care. The validity and reliability of
the HCAHPS survey are widely accepted
(O’Malley et al., 2005). These publicly avail-
able data are adjusted for patient age, edu-
cation, health status, and method of survey
administration (Lehrman et al., 2010). We
obtained hospital characteristics from the
American Hospital Association (AHA)
Annual Survey Database (2014) and county-
level unemployment rates from the Area
Health Resource File (U.S. Department of
Health & Human Services, 2013).
We included in the analysis only hospi-
tals that had an HCAHPS score for all data
points in the 2009–2013 period and merged
this information with AHA hospital-level
data. We excluded the sample hospitals in
rural areas because such hospitals operate in
a unique environment and generally have
lower occupancy rates than other hospitals
and have poor financial performance (Trinh
& O’Connor, 2000). Further exclusion
criteria included hospitals classified as fed-
eral, government, or public (nonfederal),
resulting in a final sample size of 2,059.
Dependent Variable
The outcome measure for this study is a
composite measure of the percentage of
patients who rated their overall hospital
experience as 9 or 10 on a 10-point scale.
The global rating in care is a validated
measure that estimates the overall
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© 2018 Foundation of the American College of Healthcare Executives
experience of care for each patient. We
extracted the dependent variable from the
following HCAHPS survey question:
“Where 0 is the worst hospital possible and
10 is the best hospital possible, what num-
ber would you use to rate this hospital
during your stay?” We calculated results
for each quartile from 2009 through 2013.
Each year consisted of multiple data col-
lection points, for a total of 20 time points
over the 5-year study period. Hospitals in
the top quartile for all 20 time points (with
no missing data) were sustained high-
performing hospitals and are classified
as sustainers.
Independent Variables
As discussed in the conceptual framework
section, we based predictors of sustained
hospital performance on the RBV, and they
include physical, intangible, and human
resource assets. Physical assets included
implementation of EHRs and technology
level. Intangible assets included teaching
status and complete integration of physi-
cians. Human resource assets included the
ratio of inpatient days to RNs and the
presence of hospitalists. We also incorpo-
rated in our model environmental factors,
including county-level competition and
county unemployment rate. We controlled
for for-profit ownership, Medicare share
of admissions, healthcare system member-
ship, and hospital size (measured as the
number of beds). Hospitals with a higher
share of Medicare inpatient days are ex-
posed, through VBP, to more financial
risk, for lower levels of performance on
HCAHPS surveys. System membership
facilitates access to capital, enhances the
ability to process information, and pro-
vides greater access to management
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capabilities and expertise (Madison, 2004).
Therefore, hospitals belonging to multi-
hospital systems might have better access
to the resources needed to sustain high
HCAHPS ratings. Previous research sug-
gests that hospital size also might influence
HCAHPS ratings and the hospital’s ability to
improve its ratings (Al-Amin et al., 2016;
Elliott et al., 2010). Therefore, we controlled
for hospital size in our regression model.
All hospital-level variables were de-
rived from the AHA database. We mea-
sured EHR implementation as a three-level
variable: no EHR, partially implemented
EHR, and fully implemented EHR. We
measured Medicare share of inpatient days
as the number of Medicare inpatient days
divided by the total number of inpatient
days for each hospital. Similarly, we calcu-
lated inpatient days per RN by dividing
the total number of inpatient days by the
number of full-time equivalent RNs.
Teaching status was based on whether a
hospital had a residency program approved
by the Accreditation Council for Graduate
Medical Education. We classified hospitals
as fully integrated if they adopted any of
the following arrangements with their
physicians: integrated salary model, equity
model, or foundation model (Baker et al.,
2014). An integrated salary model refers to
physician employment by the hospital,
whereas in the equity model, physicians
have ownership rights in the organization
(Burns & Muller, 2008). In the foundation
model, acquired group practices are ag-
gregated under a nonprofit entity, and the
hospital provides professional services and
plays a key role in managing the founda-
tion (Burns & Muller, 2008).
We classified hospitals as high tech-
nology if they offered any of the following
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© 2018 Foundation of the American College of Healthcare Executives
services: heart or other major organ trans-
plantation, computer-assisted orthopedic
surgery, or electron-beam computed to-
mography. Competition was estimated by
using the HHI (calculated by summing the
squares of market shares of hospital ad-
missions in a given county). For ease of
interpretation, we coded competition as
“1-HHI.” We recoded competition, unem-
ployment, Medicare share of inpatient
days, and inpatient days per RN as four-
level categorical variables based on the
25th, 50th, and 75th percentiles. We man-
aged the data and conducted diagnostic
analyses using SAS 9.4 (SAS Institute).
Statistical Analysis
We analyzed descriptive statistics for all
variables using χ2 and t tests for categorical
and continuous data, respectively. Contin-
uous variables were recoded as categorical
to allow for nonlinear associations with
hospital performance. To assess the rela-
tionship between select market and orga-
nizational characteristics and sustained
performance, we conducted a logistic re-
gression analysis. All analyses, including
descriptive and logistic regression analyses
for the final model parameters, were con-
ducted in Stata 13.1 (StataCorp).
RESULTS
Of the nearly 6,000 hospitals in the AHA
database, only 2,059 for-profit and
not-for-profit hospitals reported HCAHPS
performance for all reporting periods in
our analysis. Of these hospitals, only about
7% reported sustained first-quartile per-
formance in HCAHPS for all-time points
between 2009 and 2013. Table 1 provides
summary statistics for all variables in the
regression model.
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TABLE 1
Descriptive Statistics
Variable Percentage of Samplesa (N = 2,059)
Sustained performance
Sustainers 7
Nonsustainers 93
Electronic health records
None 2
Partial implementation 34
Full implementation 64
Medicare share of inpatient days
0%–45.47% (fewer Medicare days) 29
45.48%–52.91% 19
52.92%–61.43% 25
>61.43% (more Medicare days) 27
Inpatient days per RN
≤90.72 days (more RNs) 27
90.73–122.08 27
122.09–157.29 25
>157.29 days (fewer RNs) 21
Market competition in county based on HHI
≤0.39 (less competition) 29
0.40–0.65 27
0.66–0.85 21
>0.85 (more competition) 23
Unemployment rate in county
≤2.55% (less unemployment) 26
2.56%–2.92% 26
2.93%–3.39% 24
>3.39% (more unemployment) 24
Mean (SD) total beds in hospital 230 (228)
System membership
Yes 73
No 27
Hospitalists provide care
Yes 13
No 87
Ownership of hospital
For-profit 13
Not-for-profit 87
(continues)

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TABLE 1
Descriptive Statistics, Continued
Variable
Hospital physician integration
Fully integrated
Not fully integrated
Hospital teaching status
Teaching
Nonteaching
Technology
High
Low
Note. RN = registered nurse; HHI = Herfindahl–Hirschman Index; SD = standard deviation.
a
Unless otherwise specified.
Table 2 presents the results of the
multivariable logistic regression. As shown,
hospitals with a higher share of Medicare
inpatient days had significantly lower odds
of being sustained performers (adjusted
odds ratio [AOR] = 0.53, p < .05), whereas
the odds increased slightly as hospitals’
Medicare share of inpatient days decreased.
Hospitals with a higher ratio of inpatient
days to nurse staffing and those with
lower RN staffing levels also had the lowest
odds of being sustainers (AOR = 0.08,
p < .001); this inverse relationship became
less prominent as staffing levels increased.
Teaching hospitals (i.e., hospitals with
an accredited residency program) had
twofold greater odds of being sustainers
versus nonteaching hospitals (AOR = 2.10,
p = .016). The odds of being a sustained
performer were higher for hospitals in
areas with greater competition compared
with hospitals in less competitive markets.
Hospitals in counties with highly competitive
markets had 86% higher odds of being
sustained performers compared with hos-
pitals in the least competitive markets
(AOR = 1.86, p = .038). This positive
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© 2018 Foundation of the American College of Healthcare Executives
Percentage of Samplesa (N = 2,059)
48
52
29
71
39
61
association between competition and
sustained performance persisted among
hospitals in moderately competitive areas as
well (AOR = 1.73, p = .031).
Conversely, hospitals in areas with
the highest unemployment rates had sig-
nificantly lower odds of being sustainers
(AOR = 0.51, p = .026) compared with
those in areas with the lowest unemploy-
ment rates. However, although the adjusted
odds of having sustained performance in-
creased as the unemployment rate de-
creased, the results were not statistically
significant. Healthcare system membership,
provision of care by hospitalists, ownership
status, physician integration, implementa-
tion of EHRs, technology level, and bed size
were not significantly associated with
sustained hospital performance, according
to our logistic regression model.
DISCUSSION
In the past few years, patient satisfaction
with inpatient care has received substantial
attention from researchers and hospital
executives, given the public availability of
the data and inclusion of HCAHPS scores
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TABLE 2
Predictors of Sustained Hospital Performance: Results of Logistic Regression
Variable Odds Ratio 95% CI p Value
Electronic health record system implemented
None Reference — —
Partial implementation 0.99 0.27, 3.61 .993
Full implementation 1.21 0.34, 4.31 .773
Medicare share of inpatient days, %
0–45.47 (fewer Medicare days) Reference — —
45.48–52.91 0.59 0.34, 1.01 .054
52.92–61.43 0.58 0.35, 0.98 .040
>61.43 (more Medicare days) 0.53 0.32, 0.90 .018
Inpatient days per FTE RN
≤90.72 (more RNs) Reference — —
90.73–122.08 0.40 0.25, 0.63 .000
122.09–157.29 0.18 0.10, 0.34 .000
>157.29 (fewer RNs) 0.08 0.03, 0.18 .000
Market competition (1-HHI)
≤0.39 (less competition) Reference — —
0.40–0.65 1.73 1.05, 2.84 .031
0.66–0.85 1.85 1.04, 3.29 .036
>0.85 (more competition) 1.86 1.03, 3.33 .038
Unemployment rate, %
≤2.55 (less unemployment) Reference — —
2.56–2.92 1.14 0.73, 1.79 .559
2.93–3.39 0.72 0.42, 1.24 .238
>3.39 (more unemployment) 0.51 0.28, 0.92 .026
Total no. of beds 1.00 1.00, 1.00 .594
System membership versus no system membership (ref ) 0.79 0.53, 1.18 .250
Hospitalists provide care vs. hospitalists do not provide care (ref) 0.80 0.48, 1.34 .403
For-profit vs. not-for-profit (ref ) 1.44 0.89, 2.33 .134
Fully integrated vs. not fully integrated (ref ) 1.04 0.71, 1.53 .828
Teaching status vs. nonteaching hospital (ref ) 2.10 1.15, 3.84 .016
High vs. low technology (ref ) 1.24 0.80, 1.90 .332
Note. RN = registered nurse; FTE = full-time equivalent; HHI = Herfindahl–Hirschman Index; ref = reference category.

in VBP. Research thus far has focused on
determining organizational characteristics
associated with patient ratings (Jha, Orav,
Zheng, & Epstein, 2008; Lehrman et al.,
2010; Makarem & Al-Amin, 2014). How-
ever, few studies have been conducted on
the determinants of high levels of patient
ratings. Based on our analysis, only 7% of
hospitals sustained high patient ratings
over a 5-year period and 20 data points. A
key question for researchers and healthcare
leaders is this: What are the characteristics
that enable these hospitals to sustain high
levels of performance? More important for

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healthcare leaders is determining the
modifiable operational variables that fall
under their control and can be adjusted to
improve performance.
RN Staffing Levels
Our study findings show that the RN
staffing level is a main modifiable predictor
of sustained performance. Previous studies
provide ample evidence to support a strong
association between nurse staffing levels
and quality of care (Kane et al., 2007;
Lang, Hodge, Olson, Romano, & Kravitz,
2004; Ma, McHugh, & Aiken, 2015) and
between nursing staffing levels and patient
ratings (Makarem & Al-Amin, 2014). How-
ever, our study strengthens this evidence by
demonstrating that nurse staffing levels are
also associated with a hospital’s ability to
consistently outperform its competitors and
remain in the top 25% of hospitals that re-
ceive the highest patient ratings on the
HCAHPS survey. In a cost-containment
era when hospitals are exploring options to
improve efficiency, administrators need to
realize the importance of appropriate RN
staffing levels. Hospitals in which nurses
monitor and provide care to fewer patients
have lower failure-to-rescue rates, shorter
average lengths of stay, and lower mortality
rates (Lang et al., 2004). Moreover, a lower
patient load might enable RNs to be more
attentive to their patients and provide
more timely care and supportive services,
which contribute to higher patient ratings.
Teaching Hospitals
Our analysis also showed that teaching
hospitals had twofold greater odds of being
classified as sustainers compared with
nonteaching hospitals. This finding con-
tradicts the traditional view that teaching
www.ache.org/journals
© 2018 Foundation of the American College of Healthcare Executives
hospitals receive lower patient satisfaction
scores (Young, Meterko, & Desai, 2000).
Other studies, however, did not find a sig-
nificant association between teaching sta-
tus and patient ratings (Jha et al., 2008;
Makarem & Al-Amin, 2014). We argue
that, based on the RBV of the firm, intan-
gible resources that contribute to innova-
tiveness, learning capabilities, and knowledge
generation can enhance organizational per-
formance (Barney, Wright, & Ketchen, 2001).
Teaching hospitals are driven by a mission
that emphasizes learning and research.
Therefore, these hospitals are more likely to
embrace innovation and attain the knowledge
needed to sustain high patient ratings, thereby
outperforming other hospitals in their market.
Market-Level Factors
As expected, market-level factors were
significant predictors of hospital perfor-
mance. Hospitals with sustained high levels
of patient satisfaction are located in more
competitive markets and in counties with
lower unemployment rates. Our finding
of the association between market compe-
tition and the likelihood of a hospital sus-
taining a high level of patient satisfaction
scores is not surprising. The results of other
studies support the positive association
between hospital competition and quality
of care (Jiang, Friedman, & Begun, 2006).
Moreover, as Werner, Kolstad, Stuart, and
Polsky (2011) argue, market competition is
a necessary condition for public reporting
to have an effect. Hospitals in competitive
markets are more likely to feel pressure to
sustain high levels of patient satisfaction to
maintain or gain market share. Blustein,
Borden, and Valentine (2010) found that
hospitals in markets with richer economic
indicators received better scores on
25
Journal of Healthcare Management
......................................................................................
measures of clinical processes. Therefore,
competition is a strong, constant external
pressure that pushes hospitals to attain and
sustain high patient satisfaction ratings.
Local economic conditions also influence a
hospital’s performance and its ability to
maintain high levels of patient satisfaction.
Future comparisons between hospitals
should take into account socioeconomic
indicators such as per capita income.
Study Limitations
This study has limitations that should be
addressed in future research. Hospital
performance should be expanded to in-
clude patient outcomes such as readmis-
sion and mortality rates. Moreover, a
longitudinal study would allow a deeper
understanding of how adjustments to
modifiable factors, such as hospitalists’
staffing levels, are associated with changes
in hospital performance over time. Finally,
sustainers possess the organizational ca-
pacity to make changes and adapt effec-
tively to environmental demands. Other
resources not included in our study yet re-
lated to organizational capacity to change
include transformative leadership, culture,
and the administrative and social technol-
ogies that were described earlier. Our study
findings provide insight into the factors
associated with the likelihood of a hospital
sustaining high patient ratings over a long
period. The key determinants of sustained
performance are RN staffing levels and
teaching status. Moreover, market condi-
tions are also key determinants of hospital
performance. Future research should ex-
amine the determinants of sustained per-
formance on key patient outcomes such as
readmission rates, hospital-acquired infec-
tions, and 30-day mortality rates.
26
© 2018 Foundation of the American College of Healthcare Executives
CONCLUSION
Understanding sustained hospital perfor-
mance on the HCAHPS survey, as well as
on measures of patient outcomes, patient
safety, and efficiency, is important. By
identifying hospitals that consistently out-
perform others on key performance mea-
sures, we can investigate the characteristics
that enable them to be sustainers. Our study
findings show that RN staffing levels and
teaching status were associated with a higher
likelihood of being classified as a sustainer of
top performance on the HCAHPS survey.
Further research is needed to develop a more
holistic definition of sustainers, one that
accounts for additional key dimensions of
hospital performance.
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