Does Hospital Size Make a Difference?

by Rick Blizzard, D.B.A.
Health and Healthcare Editor

Last in a series of articles examining the effects of hospital size on patient attitudes.

When healthcare administrators look at the patient measurement data that Gallup collects for them, they frequently ask whether the size of their facility has an impact on results. Those at small facilities sometimes feel that they have inherent disadvantages relative to large facilities, and vice versa.

Common positioning strategies reinforce these perceptions. Smaller facilities are touted as strong in "high touch" attributes such as personalized care and speed and efficiency of service, while large facilities are more commonly positioned as strong in "high tech" attributes such as sophisticated technology, specialization, and the depth and breadth of available services. (For more discussion of these differences, see the previous articles of this series under Related Items.)

The Impact of Facility Size

Thus far in this series we have analyzed the impact of size upon three major outcome variables -- patient trust, patient satisfaction, and patient loyalty -- in four different service areas: inpatient, emergency department, outpatient surgery, and outpatient test and treatment. In only one instance -- patient satisfaction with the emergency department -- did the gap in average patient ratings between the highest-scoring hospital size category and the lowest-scoring size category exceed .10 on a 5-point scale. There were only three instances in which the highest and lowest scores for an individual service area occurred at opposite ends of the facility size scale (i.e., the highest score occurred among facilities with 100 beds or fewer and the lowest score among facilities with 400 beds or more).

The sample sizes involved in this analysis are extremely large, which means even small variances show up as statistically significant. But are these differences truly meaningful? The largest difference in scores rarely occurred between the smallest and largest facilities, so a meaningful advantage for either facility size rarely appeared. Even small ratings differences rarely climbed or descended in consistent linear progression by facility size.

Furthermore, the patterns of variation differ according to the specific types of patient feedback. For instance, outpatient test and treatment facilities with 400 beds or more receive high scores for patient loyalty, but low scores for patient satisfaction. Similarly, outpatient test and treatment facilities with 100 beds or fewer score lower on loyalty and higher on satisfaction.

What Does It All Mean?

Given the inconsistencies described, can any conclusions be drawn? Although there seems to be no clear relationship between facility size and patient scores on loyalty, trust, and satisfaction, we can be reasonably sure about a few things.

  • Patient loyalty, the strongest predictor of a facility's financial performance, varied the least by facility size. Only patient loyalty scores for outpatient test and treatment services clearly varied by facility size. Facility size is not a major factor in determining performance on patient loyalty measures.
  • Patient ratings of trust, satisfaction, and loyalty are subjective. They are based on both patient perceptions and patient experiences. Patients may have preconceived expectations of different facilities because of their size, and may rate facilities differently based on these expectations. The different expectations that patients hold before visiting small or large facilities may offset perceptions of their actual experiences there to some degree. For example, those visiting large facilities may have lower expectations for efficiency, while those visiting small facilities may have lower expectations for specialized expertise. The result may be reduced overall variance based on facility size.
  • Patient outcome measures are attained from patients who have already chosen and used a facility of a certain size. The patient's choice may have been influenced by his or her medical condition or service-style preference. Therefore, one should not assume a patient mix that is perfectly comparable across facility sizes.

Bottom Line

My firm conclusion is that facility size does not have a consistent effect on the way patients rate healthcare facilities. In fact, trying to find a link between a facility's size and its patient measurement scores may be a barrier to continued quality improvement. To continually improve, a hospital must successfully position itself and perform relative to all of its competitors in a particular service area -- not just those of a certain size. Healthcare facilities must strive to deliver the highest quality of service and not allow staff members to excuse shortcomings because of misperceptions about limitations due to facility size.

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