Department of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

HOSPITAL  CLOSURE:  1994

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GIBBS BROWN 
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Inspector  General 
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FEBRUARY  1996
OEI-04-95-0010()  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statuto~  mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Setvices, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the %reta~  of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providem.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
OEISAtlanta Regional Office prepared this report under the direction of Jesse J. Flowers, 
Regional Inspector General and Christopher Koehler, Deputy Regional Inspector General. 
Principal OEI staff included: 
Ron Kalil, Team Leader  Winnie Walker, Program Specialist 
Peggy Daniel, Program Analyst  Linda Moscoe, Program Analyst 
Paula Bowker, Program Analyst 
For additional copies of this report, please call the Atlanta Regional Office at (404)-331-4108. 
- Department of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

HOSPITAL  CLOSURE:  1994

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w  GIBBS BROWN 
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< Inspector  General

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FE13RUARY  1996 
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OEI-O4-95-OO1OO
 EXECUTIVE  SUMMARY

PURPOSE 
To  describe  the  extent,  characteristics,  and  impact  of hospital  closure  in  1994. 
BACKGROUND 
The  closure  of hospitals  in recent  years  has  generated  public  and  congressional  concern. 
According  to a number  of studies,  more  hospitals  are  expected  to  close in coming  years. 
Questions  have  been  raised  about  the  phenomenon  of hospital  closure,  as well as the 
implications  for public  policy. 
We  released  a report  in May  1989 describing  the  nationwide  phenomenon  of hospital 
closure  in  1987.  We  continued  our  analysis  of hospital  closure  to determine  trends  and 
effects  of the  phenomenon.  We  issued  subsequent  annual  reports  on hospital  closure  in 
1988 through  1993. 
The  findings  from  all the  previous  OIG  studies  of hospital  closure  were  similar.  The 
hospitals  that  closed  were  small  and  had  low occupancy  rates.  When  the  hospitals 
closed,  few patients  were  affected.  Most  could  get medical  care  nearby. 
FINDINGS 
Our  inspection  of hospital  closure  in 1994 produced  findings  similar  to those  previously 
reported  for  1987-1993. 
Sixteen  general,  acute  care  hospitals  closed,  continuing  a downward  trend  in the 
F	
annual  number  of closures.  This is the  lowest  number  of closings in one  year 
since we began  this series  of reports.  The  highest  number  of closures  was 88 in 
1988.  Six new general,  acute  care  hospitals  opened  in 1994, and  seven  hospitals 
that  closed  prior  to  1993 reopened  in  1994. 
Five  of the  closed  hospitals  were  rural  and  11 were  urban. 
E 
Closed  hospitals  in both  rural  and  urban  areas  were  much  smaller  than  the 
E	
national  averages. 
Rural  hospitals  that  closed  had  an average  of 19 beds  as compared  to an 
average  of 80 beds  for  all rural  hospitals  nationally. 
Urban  hospitals  that  closed  had  an average  of 97 beds  as compared  to  an 
average  of 303 beds  for all urban  hospitals  nationally. 
i  (cid:1) Occupancy  rates  for closed  rural  and  urban  hospitals  were  lower  than  the  national 
averages. 
Rural  hospitals  that  closed  had  an average  occupancy  rateof  28 percentas 
compared  to anaverageof35  percent  for all rural  hospitals  nationally. 
The  average  daily census  in theyear  prior  to closure  was about  5 patients. 
Urban  hospitals  that  closed  hadan  average  occupancy  rate  of41  percent  as 
compared  to anaverageof53  percent  for  all urban  hospitals  nationally. 
The  average  daily census  in the  year  prior  to closure  was about  39 patients. 
The  average  Medicare  utilization  of hospitals  that  closed  was about  the  same  as 
b	
all hospitals  nationally. 
In rural  areas,  the  average  Medicare  utilization  among  hospitals  that  closed 
was 55.4 percent  compared  to an average  of 55.5 percent  for all rural 
hospitals  nationally.  About  3Medicare  patients  were  inthehospital  on an 
average  day in the  year  prior  to closure. 
In urban  areas,  the  average  Medicare  utilization  among  hospitals  that 
closed  was 49.8 percent  compared  to  an average  of 47.9 percent  for all 
urban  hospitals  nationally.  About  20 Medicare  patients  were  in the 
hospital  on an average  day in the  year  prior  to closure. 
Medicaid  utilization  of hospitals  that  closed  was slightly higher  than  the  national 
E	
averages. 
In rural  areas,  the  average  Medicaid  utilization  among  hospitals  that  closed 
was  13.8 percent  as compared  to an average  of 12.8 percent  for  all 
hospitals  nationally. 
In urban  areas,  the  average  Medicaid  utilization  among  hospitals  that 
closed  was  16.7 percent  as compared  to an average  of 14 percent  for all 
urban  hospitals  nationally. 
(cid:1) Although  residents  in a few communities  had  to travel  greater  distances  for 
hospital  care,  most  had  emergency  and  inpatient  medical  care  available  within  10 
miles  of a closed  hospital. 
(cid:1) At the  time  of our  inspection,  8 of the  16 closed  hospital  facilities  (50 percent) 
were  being  used  for health-related  services.  Also, plans  were  being  made  to use  3 
of the  remaining  8 vacant  hospitals  for health-related  services. 
ii  TABLE  OF  CONTENTS

1

ExEcumm  summary  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS

Extent  and  Characteristics  of Closed  Hospitals  . . . . . . . . . . . . . . . . . . . . . ...3

How  Many  Closed  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Where  Were  They  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

What  Were  They  Like  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Impact  of Hospital  Closure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

How  Many  Patients  Were  Affected  . . . . . . . . . . . . . . . . . . . . . . . . . . ..7

Are  Inpatient  Care  and  Emergency

Servijes  Available  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

What  Is the  Building  Used  For  Now  . . . . . . . . . . . . . . . . . . . . . . . . . ..9

10

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
APPENDICES 
Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 A-1 
Number  of Hospital  Closuresby  State  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 B-1 
Hospital  Closures  byHospital  Name  andhcation  . . . . . . . . . . . . . . . . . . . .
 c-1  INTRODUCTION

PURPOSE 
To  describe  the  extent,  characteristics,  and  impact  of hospital  closure  in  1994. 
BACKGROUND 
Over  the  last decade,  closure  of general,  acute  care  hospitals  has  generated  public  and 
congressional  concern.  Numerous  questions  have  been  raised  about  the  impact  of 
hospital  closure  in the  United  States,  as well as implications  for public  policy.  A number 
of studies  predicted  that  more  hospitals  would  close  in coming  years. 
The  Office  of Inspector  General  released  a report  in May  1989 describing  the 
phenomenon  of hospital  closure  during  1987 in the  United  States.  We  found  that  the 
hospitals  that  closed  were  small  and  their  closing did not  severely  affect  access  to care. 
Many  users  of our  1987 hospital  closure  study encouraged  us to  continue  year-by-year 
analyses  of the  phenomenon  to detect  differences  in the  rate  of hospital  closure,  and  in 
the  characteristics  and  circumstances  of hospitals  that  close. 
Similar  inspections  of the  phenomenon  of hospital  closure  in  1988 through  1993 showed 
a downward  trend  in the  number  of closures. 
HOSPITAL  CLOSURE 
#  of  Clomwo=  In  U.S. 
*oo  -
80- 76 
60-
40-
20-
0-
19a7  l!aee  3989  1990  1991  1992  1993 
YEAR 
1
 The  findings  from  the  1987 through  1993 inspections  were  similar.  The  hospitals  that 
closed  were  small  and  had  low occupancy  rates.  When  the  hospitals  closed,  few patients 
were  affected.  Most  could  get medical  care  nearby. 
SCOPE 
We  examined  hospitals  that  closed  in calendar  year  1994. 
For  purposes  of this study, the  following  definitions  were  used. 
Hospital:  A facility that  provides  general,  short-term,  acute  medical  and  surgical 
inpatient  services. 
Closed Hospital:  One  that  stopped  providing  general,  short-term,  acute  inpatient 
services  in 1994.  If a hospital  merged  with or was sold to another  hospital  but  the 
physical  plant  continued  to provide  inpatient  acute  care,  it was not  considered  a closure. 
If a hospital  both  closed  and  reopened  in 1994, it was not  considered  a closure. 
METHODOLOGY 
To  determine  the  extent  and  impact  of hospital  closure,  we obtained  information  from 
State  licensing  and  certification  agencies,  State  health  planning  agencies,  State  hospital 
associations,  HCFA  data  bases,  officials  associated  with  closed  and  nearby  hospitals,  and 
local  public  officials. 
We obtained  information  on the  characteristics  of all hospitals  and  those  that  closed  in 
1994 from  the  Hospital  Cost  Report  Information  System  (HCRIS)  maintained  by HCFA. 
Appendix  A describes  our  methodology  in further  detail. 
We conducted  our  review  in accordance  with the  Quality Standards for Inspections issued 
by the  Presidents  Council  on Integrity  and  Efficiency. 
2
 FINDINGS

The  Inspector  Generals  study ofhospitals  closedin  1994 showed  that: 
	 %xteengeneral,a  cutecareh  ospitalsc  losedin  1994, continuing  a downward  trend 
in the  annual  number  of closures.  Twenty-six  fewer  hospitals  closed  in  1994 than 
in the  previous  year. 
Most  hospitals  that  closed  were  small  and  had  low occupancy  rates. 
F 
	 Although  residents  of a few communities  had  to travel  greater  distances  for 
hospital  care,  most  had  emergency  and  inpatient  medical  care  available  within  10 
miles  of a closed  hospital. 
EXTENT  AND  CHARACTERISTICS  OF CLOSED  HOSPITALS 
How Many Clad 
In  1994, there  were  5,127 general,  short-term,  acute  care  hospitals  in the  United  States 
entered  on HCFAS data  base  as participating  in the  Medicare  program.  Sixteen 
hospitals  closed  in  1994 -- 0.3 percent  of all hospitals  nationally.  Twenty-six  fewer 
hospitals  closed  in 1994 than  in the  previous  year. 
Closure  of the  16 general,  acute  care  hospitals  reduced  inpatient  bed  supply  by 1,161 
beds,  or 0.1 percent. 
While  16 hospitals  closed  in 1994, 6 new general,  acute  care  hospitals  opened,  adding  620 
beds  to the  national  supply  of beds.  In addition  to the  new hospital  openings,  7 
previously  closed  hospitals  reopened in 1994,adding  another  416 beds. 
3
 Where Were l%ey 
Theclosed  hospitals  were  locatedin  14 States.  Two States  hadtwoclosures  each,  and 
the  remaining  12 States  had  1 closure  each.  Appendix  B lists the  number  of hospital 
closures  by State.  Appendix  C lists the  closures  by hospital  name  and  location. 
About  the  same  percentage  of rural  and  urban  hospitals  closed  in 1994. 
What  Wme the Cihwd  Hmpitah Like 
~:  Hospitals  that  closed  in 1994 were  small.  Half  the  hospitals  that  closed  had  50 
beds  or less. 
~ti 
~F~S13D  ~@P~&-Si 
Number  of Closed  Hospitals 
Number  of Beds  Rural  Urban  Total 
0-30  4  1  5 (31%) 
31-50  1  2  3 (19%) 
51-100  0  6  6 (38%) 
101-200  0  1  1 (6%) 
201-300  0  1  1 (6%) 
301>  0 
Totals  5 
:1  b 
4
 Both  the  rural  and  urban  hospitals  that  closed  in 1994 were  considerably  smaller  than  the 
average  size of rural  and  urb~n  general,  acute  care  hospitals  nationally. 
HOSPITALS  THAT  CLOSED 
WERE  SMALL 
==0  _#  of  Beds 
303 
300   
260   
200   
150 
loo 
60   
o 
RURAL  HOSPITALS  URSAN  HOSPITALS 
- National  Avg  - ClosciDd  Hospital  Avg 
Occupancy  rates  for closed  rural  and  urban  hospitals  were  lower  than  the 
w 
national  averages.l 
OCCUPANCY  RATES  WERE  LOW 
60%   
62.7% 
60%   
40%    36.2% 
/ A 
30%   
20%   
lo% 
0%   
RURAL  HOSPITALS  URBAN  HOSPITALS 
- Nationai  Avg  - Cios.ci  H.spitai  A.g 
5
 Medicare  Utilization:  ~eaverage  Medicare  utilimtion  among  rural  hospitals  that  closed 
was about  the  same  as rural  hospitals  nationally.  The  average  Medicare  utilization 
among  urban  hospitals  that  closed  was slightly higher  than  the  national  average.z 
MEDICARE  UTILIZATION 
70%   
so%    65.6%  5s.4% 
49.s% 
47.9% 
60%   
40%   
so%   
20%   
lo% 
0%   
RURAL  HOSPITALS  URBAN  HOSPITALS 
- National  Avg  - closed  Hospital  Avg 
Medicaid  Utilization:  In both  rural  and  urban  areas,  the  average  Medicaid  utilization 
among  hospitals  that  closed  was higher  than  the  national  averages.3 
MEDICAID  UTILIZATION 
20% 
1 s% 
1 e% 
14% 
1 2% 
1 o% 
e% 
en 
4% 
2% 
o% 
RURAL  HOSPITALS  URBAN  HOSPITALS 
- National  Avg  - Closed  Hospital  Avg 
6
 IMPACI  OF HOSPITAL  CLOSURE 
Incommunities  where  hospitals  closedin  1994, we assessed  the

E  number  of patients  affected  by closure  of hospitals,

F  availability  of inpatient  care  and  emergency  medical  services,  and

b  current  use  of closed  hospital  facilities.

How hill  Patienb WereAfiected 
For  rural  hospitals  that  closed  in 1994, the  average  daily census  in the  year  prior  to 
closure  was about  5 patients.  The  urban  hospitals  that  closed  had  an  average  daily 
census  of about  39 patients. 
Rural  Hospitals  Urban  Hospitals 
Average  Number  of Beds  18.8  97.0 
Average  Occupancy  Rate  27.8.$ZO  40.6% 
X  X 
Average  Number  of Patients  5.2  39.4 
We analyzed  Medicare  utilization  data  to determine  the  number  of elderly  patients 
affected  by hospital  closure  in 1994.  In rural  hospitals  that  closed,  about  3 Medicare 
patients  were  in the  hospital  on an average  day in the  year  prior  to closure.  In the  urban 
hospitals  that  closed,  about  20 Medicare  patients  were  in the  hospital  on an  average  day. 
Rural  Hospitals  Urban  Hospitals 
Average  Patient  Census  5.2  39.4 
Average  Medicare  Utilization  Rate  x 55.470  49.89Z0 
X 
Average  Number  Medicare  Patients  2.9  19.6 
7
 Are InpatikruCare&  EmergencySenicesAvaikble 
We assessed  availability  of inpatient  and  emergency  medical  care  in miles  from  a closed 
hospital  to the  nearest  inpatient  and  emergency  facilities. 
Imatient  Care:  In most  communities  where  a hospital  closed  in 1994, inpatient  hospital 
care  was available  nearby. 
NUMBER  OF  CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within  3 Miles  1 (20%)  6 (55%) 
4-10Miles  o	 5 (45%) 
o 
11-20 Miles  3 (60%) 
21-30Miles  1 (20%)  o 
More  than  30 Miles  o  0 
Totals  5 (loo%)  11 (loo%) 
Rural Areas:  Residents  in 4 of the  5 rural  communities  (80 percent)  where  a hospital 
closed  could  get  inpatient  hospital  care  within  20 miles  of the  closed  hospital.  However, 
residents  of Philipsburg,  Montana  had  to travel  30 miles  for full service inpatient  hospital 
care.  This  frontier  community  converted  its closed  hospital  into  a Medical  Assistance 
Facility  (MAF).  The  3-bed  MAF  facility provides  up to four  days of limited  inpatient 
semices. 
Urban Areas:  In all  11 urban  communities  where  a hospital  closed  in  1994, residents 
could  get  inpatient  hospital  care  within  10 miles  of the  closed  hospital.  Seven  of the 
eleven  urban  communities  (64 percent)  where  a hospital  closed  could  get inpatient  care 
in the  same  town. 
Ememenw  Services:  When  a hospital  closed,  the  community  lost not  only inpatient  beds, 
but  also 24-hour  emergency  services. 
Rural Areas:  In all 5 rural  communities  where  a hospital  closed  in 1994, emergency  care 
facilities  were  available  within  20 miles  of the  closed  hospital. 
Urban Areas:  In all 11 urban  communities  where  a hospital  closed  in  1994, emergency 
care  facilities  were  available  within  10 miles  of the  closed  hospital.  Eight  of the  11 urban 
8
 communities  (73 percent)  where  a hospital  closed  could  get  emergency  services  in the 
same  town. 
ii@RWK!Y  iC@L @f3i3
NEAREST S3RVI@  HWi@ii@  .. 
NUMBER  OF  CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within  3 Miles  2 (40%)  7 (64%) 
4-10 Miles  o  4 (36%) 
11-20 Miles  3 (60%)  o 
21-30 Miles  o  0 
More  than  30 Miles  o  0 
Totals  5 (loo%)  11 (loo%) 
L. 
~  Is the hikiing  thd  For NOW 
At the  time  of our  review,  8 of the  16 closed  hospital  buildings  (50 percent)  were  being 
used  for health-related  services.  For  example: 
Physicians  and  Surgeons  Hospital  in Shreveport,  Louisiana  became  a nursing 
b	
home  and  substance  abuse  facility. 
	 Winthrop  Hospital  in Winthrop,  Massachusetts  is now a 24-hour  urgent  care 
center. 
Lumberton  Citizens  Hospital  in Lumberton,  Mississippi  was converted  to a home 
F	
health  agency  and  doctors  office. 
	 Granite  County  Memorial  Hospital  in Philipsburg,  Montana  was converted  to a 
HCFA  sponsored  Medical  Assistance  Facility.  In addition  to providing  limited 
inpatient  care,  it provides  24-hour  emergency  services  and  outpatient  care.  The 
Office  of Inspector  General  released  a report  on Medical Asszktance Facilities 
(OEI-04-92-O0731)  in July  1993. 
At the  time  of our  review,  community  officials were  planning  to use 3 of the  remaining  8

vacant  hospitals  for health-related  services.  Lakefield  Municipal  Hospital  in Lakefield,

Minnesota  will be  converted  to an assisted  elderly  living facility.  Also,  community

officials in two locations  where  hospitals  closed  plan  to reopen  the  facility as acute  care

hospitals.

9
 ENDNOTES

1.	 Hospital  occupancy  rate  is defined  as the  actual  number  of patient  days divided  by 
the  total  bed  days available.  National  average  occupancy  rate  is defined  as the 
sum  of all hospitals  occupancy  rates,  divided  by the  number  of hospitals. 
2.	 Average  Medicare  utilization  of closed  rural  and  urban  hospitals  is defined  as the 
percent  of Medicare  patient  days compared  to the  total  patient  days for  each 
hospital,  summed  and  divided  by the  number  of hospitals.  National  average 
Medicare  utilization  is the  percent  of Medicare  utilization  of each  hospital, 
summed  and  divided  by the  total  number  of hospitals. 
3.  Medicaid  utilization  is calculated  in the  same  way as Medicare  utilization. 
10
 APPENDIX  A
METHODOLOGY 
Extentof Hmpitol Closure 
To  determine  how many  hospitals  closed  in 1994, we surveyed  State  licensing  and 
certification  agencies,  State  hospital  associations,  and  State  health  planning  agencies.  We 
also compiled  Health  Care  Financing  Administration  (HCFA)  data  on terminated 
providers  in  1994.  When  a closed  hospital  met  the  studys definition  or when  there  were 
questions,  we contacted  officials  associated  with the  closed  hospitals,  officials  associated 
with hospitals  nearest  to the  closed  hospital,  and  local  public  officials. 
To  determine  the  number  of hospitals  in the  United  States,  we used  the  Hospital  Cost 
Report  Information  System  (HCRIS)  maintained  by HCFA.  We included  only general, 
short-term,  acute  care  hospitals  under  Medicares  Prospective  Payment  System  (PPS)  in 
the  universe.  There  were  5,127 hospitals  listed  on HCRIS  as short-term,  acute  care, 
general  hospitals  for the  tenth  year  of PPS (PPS  10). 
Charucteridcsof Hqpital Cl&ure 
To  analyze  characteristics  of closed  hospitals,  we used  HCRIS  data.  We  used  the  latest 
pre-closure  cost reports.  For  example,  if a hospital  closed  in May  1994 and  its 
accounting  year  was on a January-December  cycle, we used  the  providers  January  1, 
1993 to December  31, 1993 report. 
Impct  of Hapital Closure 
We limited  our  impact  analysis  to the  distance  from  a closed  hospital  to the  nearest 
still-operating  hospitals  and  to emergency  services.  We  obtained  data  for  our  analysis 
from  interviews  with the  following  sources. 
  Former  hospital  administrators,  board  members,  and/or  staff  of closed  hospitals 
  Hospital  administrators  and/or  staff at the  nearest  hospitals 
  Local  police,  health,  and  government  officials 
State  health  planning  agencies 
F 
E  State  certification  and  licensing  agencies 
  State  hospital  associations 
A -1

_  B-1  APPENDIX  C
Hospital  Name
 City 
Los Medanos  Community  Hospital
 Pittsburg  CA  urban 
Destin  Hospital
 Destin  FL  urban 
Woodstock  Hospital
 Woodstock  GA  urban 
Wellington  Hospital  and  Clinic
 Wellington  KS  rural 
Physicians  and  Surgeons  Hospital
 Shreveport  LA  urban 
Winthrop  Hospital
 Winthrop  urban 
Lakefield  Municipal  Hospital
 Lakefield  MN  rural 
Healtheast  Divine  Redeemer  Hospital
 South  St. Paul  MN  urban 
Lumberton  Citizens  Hospital
 Lumberton  MS  rural 
Granite  County  Memorial  Hospital
 Philipsburg  rural 
Medical  Arts  Center  Hospital
 New York  NY  urban 
Parkview  Hospital
 Toledo  OH  urban 
Sacred  Heart  Hospital
 Norristown  PA  urban 
Doctors  Memorial  Hospital
 Spartanburg  Sc  urban 
Lee  County  Memorial  Hospital
 Bishopville  Sc  rural 
Metropolitan  Hospital
 Chattanooga  TN  urban 
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