The 2007 State of America’s Hospitals –

Taking the Pulse

Findings from the 2007 AHA Survey of Hospital Leaders

July 2007

Executive Summary

• Hospitals face workforce shortages that are affecting patient care.• Hospitals had an estimated 116,000 registered nurse vacancies

as of December 2006.• Nearly half of emergency departments (ED) are “at” or “over”

capacity.• A majority of urban hospitals experience time on diversion.• The most common reason for diversion is lack of staffed critical

care beds.• 55% of hospitals experienced gaps in specialty coverage in the ED.

• Many hospitals are reporting increased difficulty maintaining physician ED call coverage.

• More than a third of hospitals now pay for some physician specialty ED call coverage.

• Coverage issues are most prevalent in orthopedics and neurosurgery.

• Hospitals are taking a variety of actions to bolster disaster readiness including participation in large scale drills, establishing back-up communications plans and developing resource sharing plans with other hospitals.

Survey Methodology

• Survey was sent to approximately 5,000 community hospital CEO’s in late February 2007 via fax and Email.

• Data was collected through March 2007.• Unless otherwise specified, data reflects the above

mentioned time period.• A total of 840 responses were received, a response rate

of approximately 17%.

Overview

• Workforce• Hospital Capacity, Emergency Department Diversion

and Specialty Coverage• Disaster Readiness

2007 Survey Results

WORKFORCE

Vacancy Rates for Selected Hospital Personnel, December 2006

Hospitals face workforce shortages in key care-giving professions…

8.1% 8.1% 8.0%

6.6%5.9% 5.9%

11.4%

Therapists (ST, OT, PT)

RegisteredNurses

Pharmacists NursingAssistants

LPNs LaboratoryTechnicians

ImagingTechnicians

Source: 2007 AHA Survey of Hospital LeadersNote: 116,000 vacancies is a national estimate created by extrapolating the vacancy rate to all 5,000 community hospitals in 2005. ST: Speech Therapist, OT: Occupational Therapist, PT: Physical Therapist.

116,000 RN Vacancies*

..that are perceived to be getting worse…

IT Technologists

Housekeeping/ Maintenance

Nursing Assistants

LPNs

Billing/Coders

Laboratory Technicians

Imaging Technicians

Pharmacists

Registered Nurses

Percent of Hospitals Reporting Recruitment More Difficult in 2006 vs. 2005

Source: 2007 AHA Survey of Hospital Leaders.

17%

19%

20%

22%

28%

28%

41%

44%

44%

58%

0% 10% 20% 30% 40% 50% 60% 70%

Therapists (Speech,Occupational and Physical)

…and are affecting patient care.

6%

8%

9%

13%

13%

17%

17%

21%

35%

36%

49%

ED Overcrowding

Diverted ED Patients

Reduced Number of Staffed Beds

Increased Wait Times to Surgery

Discontinued Programs/ Reduced Service Hours

Delayed Discharge/ Increased Length of Stay

Cancelled Surgeries

Curtailed Acquisition of New Technology

Curtailed Plans for Facility Expansion

Type o

f Im

pa

ct

Source: 2007 AHA Survey of Hospital Leaders

Percent of Hospitals Reporting Service Impacts of Workforce Shortage, 2006

Decreased Patient Satisfaction

Decreased Staff Satisfaction

17 percent of hospitals reported hiring foreign-educated* nurses in 2006.

No 83%

Yes 17%

Percent of Hospitals Reporting that They Hired Foreign-educated* Nurses to Help Fill RN Vacancies in 2006

Source: 2007 AHA Survey of Hospital Leaders*Foreign-educated nurses are individuals who are foreign born and received basic nursing education in a foreign country. In general many of these nurses come to the US on employment visas which allow them to obtain a green card.

42 percent of hospitals reported that they hired more foreign-educated* nurses in 2006 vs 2005.

Same 35%

More 42%

Less 23%

Percent of Hospitals Reporting More, Less or the Same Number of Foreign-educated* Nurses to Fill Vacancies in 2006 vs 2005

Source: 2007 AHA Survey of Hospital Leaders*Foreign-educated nurses are individuals who are foreign born and received basic nursing education in a foreign country. In general many of these nurses come to the US on employment visas which allow them to obtain a green card.

84 percent of those hospitals hiring foreign-educated nurses recruited from the Philippines.

84%

33%29%

9% 7% 6%

Philippines Canada India Africa China Korea

Source: 2007 AHA Survey of Hospital Leaders

Percent of Hospitals Hiring Foreign-educated Nurses by Country from which They Recruited, 2006

2007 Survey Results

HOSPITAL CAPACITY, EMERGENCY DEPARTMENT DIVERSION AND

SPECIALTY COVERAGE

25%

24%

27%

20%

30%

23%

18%

46%

11%

35%

0% 10% 20% 30% 40% 50% 60% 70% 80%

All Hospitals

Non-teaching Hospitals

Teaching Hospitals

Rural Hospitals

Urban Hospitals

ED is "At" Capacity ED is "Over" Capacity

Nearly half of EDs are “at” or “over” capacity…

Percent of Hospitals Reporting ED Capacity Issues by Type of Hospital, 2007

Source: AHA 2007 Survey of Hospital Leaders

65%

31%

73%

42%

48%

…and a majority of urban and teaching hospitals experience time on ED diversion…

Percent of Hospitals Reporting Time on Diversion in Last 12 Months

36%

30%

64%

17%

56%

0% 10% 20% 30% 40% 50% 60% 70%

All Hospitals

Non-teaching

Teaching

Rural

Urban

Source: AHA 2007 Survey of Hospital Leaders

4%

7%

12%

17%

29%

30%

0% 10% 20% 30% 40%

…most often caused by a lack of staffed critical care beds.

Percent of Hospitals Citing Factor as Number One Reason for Ambulance Diversion, January 2007

Source: AHA 2007 Survey of Hospital Leaders

Lack of Staffed Critical Care Beds

ED Overcrowded

Lack of General Acute Care Beds

Staff Shortages

Lack of Specialty Physician Coverage

Lack of Psychiatric Beds

Percent of Time on Diversion in January 2007(Among Urban Hospitals Experiencing Diversion in the Last 12 Months)

20%

58%

13%

9%

0% 10% 20% 30% 40% 50% 60% 70%

20% or More of Time

10-19.9% of Time

Up to 9.9% of Time

No Diversion Time

For urban hospitals reporting diversion, nearly one in eight was on diversion more than 20 percent of the time.

Source: AHA 2007 Survey of Hospital Leaders

Percent of Urban Hospitals Experiencing Diversion

Percent of Timeon Diversion

42 percent of hospitals reported an increase in “boarding” behavioral health patients in the ED.

Percent of Hospitals Reporting Increases in “Boarding” Behavioral Health Patients in the ED by Type of Hospital

Source: AHA 2007 Survey of Hospital LeadersNote: Boarding is a term used when patients that are in need of inpatient psychiatric or substance abuse services remain in the emergency department until a suitable placement can be found.

27%

26%

31%

22%

32%

15%

13%

21%

11%

19%

0% 10% 20% 30% 40% 50% 60% 70%

All Hospitals

Non-teaching Hospitals

Teaching Hospitals

Rural Hospitals

Urban Hospitals

Moderate Increase Significant Increase

51%

33%

52%

39%

42%

Percent of Hospitals Losing Specialty Coverage in the ED for Any Period of Time in Last 24 Months and Reasons Cited

26%

26%

37%

41%

55%

6%

6%

10%

11%

Physician liability concerns

Competition from specialty hosptial

Competition from another hospital

Competition from Ambulatory Surgery Center

Unaffordable on-call coverage

Physician retired or left

Inability to attract physicians

Physician lifestyle issues

Percent losing specialty coverage

55 percent of community hospitals experienced gaps in specialty coverage in the ED.

Source: AHA 2007 Survey of Hospital Leaders. *Respondents could check more than one reason for loss of specialty coverage.

Percent of Above Citing

Reason as Factor in Loss of Coverage*

Maintaining ED coverage is becoming more difficult for many hospitals in key specialty areas.

Percent of Hospitals Reporting Increased Difficulty in Maintaining Physician ED Call Coverage by Selected Specialty in 2007

Source: AHA 2007 Survey of Hospital Leaders

10%

11%

14%

15%

19%

21%

18%

22%

23%

19%

22%

8%

10%

9%

10%

13%

13%

18%

14%

17%

24%

22%

OB/GYN

Ophthalmology

GI

Vascular Surgery

ENT

General Surgery

Hand Surgery

Plastic Surgery

Psychiatry

Neurosurgery

Orthopedics

Somewhat more difficult Significantly more difficult

44%

43%

40%

25%

36%

34%

32%

36%

23%

21%

18%

Gaps in coverage were most often reported for orthopedics and neurosurgery.

Percent of Hospitals Reporting Loss of Specialty Coverage for Any Period of Time in 2007

Source: AHA 2007 Survey of Hospital Leaders

7%

9%

10%

15%

15%

19%

19%

21%

22%

25%

26%

OB/GYN

Psychiatry

GI

Ophthalmology

Vascular Surgery

General Surgery

ENT

Hand Surgery

Plastic Surgery

Neurosurgery

Orthopedics

More than a third of hospitals pay for some physician ED on-call coverage.

Percent of Hospitals Reporting Payment for ED On-call Coverage by Specialty, 2007

Source: AHA 2007 Survey of Hospital Leaders

2%

5%

3%

6%

6%

7%

9%

8%

12%

9%

16%

1%

2%

2%

2%

2%

2%

3%

4%

4%

4%

5%

6%

6%

8%

8%

9%

11%

10%

13%

15%

20%

16%

Ophthalmology

GI

ENT

Vascular Surgery

Plastic Surgery

Hand Surgery

Psychiatry

OB/GYN

Orthopedics

Neurosurgery

General Surgery

Some Most All

37%

33%

31%

16%

22%

21%

18%

25%

13%

13%

9%

2007 Survey Results

DISASTER READINESS

1%

3%

11%

86%

The majority of hospitals reported taking part in a large-scale drill with external response agencies.

Hospitals Participating in Large-scale Community-wide Drills with External Response Agencies in 2006

Source: AHA 2007 Survey of Hospital Leaders

Yes, have already taken action

No, but plan to take action in 6-12 months

No, but plan to take action when resources permit

No action planned

2%

5%

8%

85%

85 percent of hospitals have established back up systems for communication with police, fire etc.

Percent of Hospitals with Established Back-up Community-wide Communications Ability, 2006

Source: AHA 2007 Survey of Hospital Leaders

Yes, have already taken action

No, but plan to take action in 6-12 months

No, but plan to take action when resources permit

No action planned

Chart 1.5: National Expenditures for Health Services and Supplies(1) by Category, 1980 and 2005(2)

7.5% 8.3%11.2%

14.8% 11.1%11.8%

27.3%

12.6%10.2%

23.7%

23.8%

13.0%

16.1%

23.4%

21.0%

6.7%

12.4%

15.2%

3.7%8.1%

17.2%

0-2 Hours 3-12 Hours 12+Hours

30 or more beds

20-29 beds

10-19 beds

5-9 beds

1-4 beds

No AdditionalBedsUnknown

Source: AHA 2007 Survey of Hospital Leaders

Number of Staffed Beds Hospitals Estimate Could be Available in the Following Time Periods in the Event of a Disaster, 2007

The majority of hospitals have the ability to add more bed capacity in the event of a disaster.