National Daily Hospital Executive Briefing
Focus Topics Today: Hospital Margin & Rural Viability; ED Throughput & Boarding; Patient Safety & Nurse Burnout
1. Hospital Margin, Revenue, and Rural Hospital Viability
News – Performance gap widens between top and bottom hospitals
Kaufman Hall’s latest flash report shows adjusted year-to-date hospital operating margin holding around 2.9%, but with a widening spread: top-quartile hospitals at about 14.7% margin versus –1.8% in the bottom quartile, and labor now averaging 84.2% of total expenses, with supplies up 26% and drug costs up 31% compared with 2022.
https://www.healthcarefinancenews.com/news/financial-performance-gap-widens-between-top-bottom-hospitals-report-finds Healthcare Finance NewsNews – Rural hospital distress remains severe
A 2025 Chartis “State of Rural Health” analysis finds 46% of rural hospitals operating at a loss, with 432 facilities vulnerable to closure and 18 rural hospitals closing or converting away from inpatient care in the last year, bringing total closures/conversions since 2010 to 182.
https://www.chartis.com/insights/2025-rural-health-state-state ChartisNews/Recommendation – AHA warns of persistent cost pressures
The American Hospital Association’s 2025 “Cost of Caring” update reports that hospitals continue to face elevated labor, drug, supply, and cyber-security costs, and urges policymakers to avoid additional payment cuts while expanding targeted support (e.g., rural stabilization programs, workforce funding, and relief for drug and supply inflation).
https://www.aha.org/press-releases/2025-04-30-new-aha-report-hospitals-and-health-systems-squeezed-persistent-economic-challenges American Hospital Association+1Case Study – Single critical-access hospital kept open with emergency funding
Catalina Island Health, California’s only island hospital and a designated critical access facility, avoided near-term closure after Los Angeles County approved a $3 million emergency lifeline, illustrating how targeted local funding can preserve essential ED and inpatient services but also highlighting the fragility of small, isolated hospitals.
https://www.sfgate.com/bayarea/article/catalina-island-hospital-funding-20267460.php SFGATENews – Rural closures and access risk continue to escalate
A national analysis from the Center for Healthcare Quality and Payment Reform estimates that hundreds of rural hospitals are at immediate or high risk of closure, with more than 100 rural hospitals already closed over the past decade and dozens more having eliminated inpatient services, eroding local access to ED and obstetric care.
https://chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf Chqpr
2. Hospital Emergency Department Throughput and Boarding
News – National ED access failures and boarding times are worsening
A new national ED Quality Composite (ECCQ) analysis shows ED “access failures” rising from 18.5% to 28.7% between 2017 and 2024, with the share of visits exceeding 8 hours in the ED increasing from 7.8% to 13.9% and boarding over 4 hours increasing from 2.6% to 6.2%, especially among patients with mental health conditions.
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2832437 JAMA NetworkNews/Case Study – Age-Friendly Hospital ED measures for older adults
A research letter and related implementation work from Hebrew SeniorLife describe the new CMS/AHRQ Age-Friendly Hospital Measure, which will require hospitals to keep ED stays for older adults under 8 hours and limit time from bed request to admission to 3 hours, using these thresholds as benchmarks for redesigning geriatric ED flow.
https://www.hebrewseniorlife.org/news/age-friendly-hospital-measure-helps-lower-healthcare-risks-older-adults-after-ed-visits hebrewseniorlife.org+1Case Study – Prolonged ED stays for older adults are increasingly common
A JAMA Internal Medicine research letter summarized by AJMC, using Epic Cosmos data from 1,633 hospitals, finds that prolonged ED stays and boarding times for adults 65+ increased substantially between 2017 and 2024, with extended stays linked to higher risks of delirium, mortality, treatment delays, and worse patient experience—underscoring the need to meet the Age-Friendly ED targets.
https://www.ajmc.com/view/prolonged-ed-stays-boarding-times-among-older-adults-underscore-systemic-hospital-strain AJMCCase Study – Pediatric mental health boarding crisis
A national study of pediatric mental health ED visits finds that 32.1% of children and adolescents presenting with a mental health crisis experienced boarding of 12 hours or more, largely due to shortages of inpatient psychiatric beds and limited community options, with prolonged waits associated with medication errors and reduced ED throughput.
https://www.ajmc.com/view/1-in-3-minors-facing-mental-health-crisis-experience-12-hour-ed-waits AJMCRecommendation – Use ED LOS as both safety and financial metric
Multi-country studies increasingly show that prolonged ED length of stay is associated with higher in-hospital mortality, poorer patient satisfaction, and longer overall hospital LOS, making ED LOS a dual patient-safety and cost metric that should be tracked alongside boarding hours in daily operations reviews.
https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-025-01283-z BioMed Central
3. Patient Safety and Culture of Safety (with a Focus on Nurse Burnout)
News – Hospital workplace safety culture remains mixed
AHRQ’s 2024 Workplace Safety Supplemental Items survey, completed by over 75,000 staff across 447 hospitals, found an average 74% positive rating for “overall workplace safety,” but only about 49% positive for how often hospitals address verbal and physical aggression toward staff, with ED units among the lowest-scoring areas.
https://www.ahrq.gov/sops/surveys/hospital/workplace-safety/index.html AHRQNews/Recommendation – Nurse burnout is directly tied to safety and quality
A JAMA Network Open systematic review and meta-analysis of 85 studies including 288,581 nurses concludes that higher nurse burnout is consistently associated with a worse safety climate, more nosocomial infections, falls, medication errors, and other adverse events, as well as lower patient satisfaction and nurse-assessed quality of care.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825639 JAMA Network+1Case Study – Safety culture and incident reporting
Recent hospital-based studies show that units with stronger safety culture scores—particularly on teamwork, open communication, and non-punitive response to error—report more near-misses and incidents and have fewer serious adverse events, reinforcing that high-reporting environments can be a marker of safer systems rather than poorer care.
https://bmjopen.bmj.com/content/14/5/e080094 BioMed CentralNews – AHA reports progress but persistent gaps in patient safety
An AHA update on hospital quality and safety notes that while rates of several hospital-acquired conditions have fallen since their pre-pandemic peak, serious preventable harm and workforce safety incidents remain unacceptably common, and calls for integrated safety strategies that address both patient outcomes and staff well-being.
https://www.aha.org/news/headline/2025-03-10-hospitals-report-progress-patient-safety-more-work-needed American Hospital AssociationNews – National data show preventable harm remains high
National reporting data continue to show thousands of serious preventable hospital adverse events annually, with recent analyses noting year-over-year increases in severe harms; investigators emphasize that staffing, burnout, and ED/bed crowding are key systemic drivers.
(Example summary; may require subscription.)
https://www.washingtonpost.com/health/2025/02/20/hospital-medical-errors-patient-harm/ The Washington Post
Quality Metrics to Share with Your Team (≤ 7)
Margins and financial spread
National hospital data show an adjusted year-to-date median operating margin of ~2.9%, with margins ranging from 14.7% for top-quartile hospitals to –1.8% for bottom-quartile facilities, while labor accounts for 84.2% of total expenses and non-labor costs (supplies and drugs) have risen 26–31% since 2022.
https://www.healthcarefinancenews.com/news/financial-performance-gap-widens-between-top-bottom-hospitals-report-finds Healthcare Finance NewsRural hospital distress
Across the U.S., 46% of rural hospitals are operating with negative margins and 432 are classified as vulnerable to closure, with 18 rural hospitals closing or converting away from inpatient care in the last year and 182 closures/conversions since 2010.
https://www.chartis.com/insights/2025-rural-health-state-state ChartisED access failures and prolonged stays (all adults)
ED “access failures” increased from 18.5% to 28.7% between 2017 and 2024, while the proportion of visits with ED length of stay >8 hours rose from 7.8% to 13.9%, and the share of boarded patients waiting >4 hours increased from 2.6% to 6.2%, with mental health patients disproportionately affected.
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2832437 JAMA NetworkED boarding in older adults
Using data from 1,633 hospitals in Epic Cosmos, a national analysis of older adults (65+) shows substantial increases in both ED stays over 8 hours and boarding times over 3 hours, with prolonged stays linked to higher delirium and mortality risk; these metrics underlie the new Age-Friendly Hospital ED measure.
https://www.ajmc.com/view/prolonged-ed-stays-boarding-times-among-older-adults-underscore-systemic-hospital-strain AJMC+1Pediatric mental health ED boarding
National survey data estimate that 32.1% of pediatric mental health ED visits involved 12 hours or more in the ED before admission or transfer, with most children cared for in non-children’s hospitals and prolonged boarding associated with higher risk of medication errors and ED crowding.
https://www.ajmc.com/view/1-in-3-minors-facing-mental-health-crisis-experience-12-hour-ed-waits AJMCWorkplace safety perceptions
AHRQ’s 2024 workplace safety survey across 447 hospitals found an average 74% positive rating on overall workplace safety, but only 49% positive on how often hospitals address aggression and abuse toward staff, with ED units among the lowest performers.
https://www.ahrq.gov/sops/surveys/hospital/workplace-safety/index.html AHRQImpact of nurse burnout on safety and quality
A meta-analysis of 85 studies / 288,581 nurses found that higher burnout is associated with a moderately worse safety climate (Cohen’s d ≈ –0.68), more nosocomial infections, falls, medication errors, and adverse events, and lower patient satisfaction, reinforcing burnout as a leading indicator of safety risk.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825639 JAMA Network+1
Leadership Call to Action (≤ 5)
Put margins and risk on a single, visible dashboard
Build a finance dashboard that shows operating margin by site/service line, flags units or affiliates with negative margins, overlays rural/critical access status, and links to throughput and workforce indicators so boards and executives can see where margins and access risk are converging.Launch a 90-day ED boarding and LOS sprint
Treat ED LOS and boarding as top-tier safety and financial metrics: set local targets aligned with the Age-Friendly Hospital and ECCQ thresholds (e.g., <8-hour ED LOS and <3-hour bed-request-to-admit for older adults; no pediatric mental health boarders beyond 12 hours), and run a structured rapid-cycle improvement effort with daily flow huddles.Integrate ED, inpatient, and case management in one daily “flow command center”
Formalize a multidisciplinary bed-placement huddle (ED, hospital medicine, surgery, case management, behavioral health, and hospital-at-home) to review current and predicted boarding, prioritize discharges, escalate placement barriers, and coordinate with rural network partners where transfers are at risk.Build a safety-and-burnout bundle for frontline staff
Combine violence-prevention protocols, reliable incident reporting, de-escalation training, and evidence-based staffing and well-being supports into a single safety bundle, and measure impact using AHRQ’s safety and workplace safety surveys plus regular burnout assessments.Align advocacy and strategy around rural access and vulnerable services
Use the Chartis, CHQPR, and AHA data to quantify your system’s exposure to rural hospital risk, obstetric and behavioral health service closures, and ED boarding hot spots, then align board-level strategy and external advocacy (state/federal programs, rural stabilization funds, Medicaid policy) around preserving essential local access.
📍 Published at National Daily Hospital News
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Published as part of the National Daily Hospital News series.
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Editor: Spence Tepper
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