Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
HOSPITAL CLOSURE: 1997 
JUNE GIBBS BROWN 
Inspector General 
JANUARY 1999 
OEI-04-98-00200  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Atlanta 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: 
REGION  HEADQUARTERS 
Graham Rawsthorn, Team Leader
 Tricia Davis, Program Specialist 
Ron Kalil, Contractor
 Scott Horning, Technical Support 
Greg Jones, Program Analyst

Janet Miller, Program Analyst

Peggy Daniel, Program Analyst
 E X E C U T I V E  S U M M A R Y

PURPOSE 
To describe the extent, characteristics, reasons for, and impact of hospital closure in 1997. 
BACKGROUND 
The closure of hospitals in past years has generated public and congressional concern.  We 
released a report in May 1989 describing the nationwide phenomenon of hospital closure in 1987. 
Subsequently, we issued annual reports for hospital closures from 1988 through 1996. 
The findings from all the OIG studies of hospital closures are 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 closures in 1997 produced findings similar to those previously reported 
for 1987-1996. 
!	 Thirty-eight general, acute care hospitals closed -- 0.8 percent of all hospitals.  One more 
hospital closed in 1997 than in each of the previous two years.  Two new general, short 
term, acute care hospitals opened in 1997, and one hospital that had previously closed 
reopened in 1997. 
!	 Ten of the closed hospitals were rural and 28 were urban.  A higher percentage of urban 
hospitals (1.1%) closed in 1997 than did rural hospitals (0.5%). 
!	 Closed hospitals in both rural and urban areas were smaller on average than the national 
averages. 
Rural hospitals that closed had an average of 48 beds as compared to an average 
of 68 beds for all rural hospitals nationally. 
Urban hospitals that closed had an average of 122 beds as compared to an average 
of 222 beds for all urban hospitals nationally. 
!	 Occupancy rates for closed rural and urban hospitals were lower on average than the 
national averages. 
Rural hospitals that closed had an average occupancy rate of 26.9 percent as 
compared to an average of 32 percent for all rural hospitals nationally.  The 
average daily census in the year prior to closure was about 13 patients. 
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i  Urban hospitals that closed had an average occupancy rate of 38.8 percent as 
compared to an average of 48 percent for all urban hospitals nationally.  The 
average daily census in the year prior to closure was about 47 patients. 
!	 Medicare utilization in closed hospitals was higher than the national average for rural 
hospitals, and lower for urban hospitals. 
In rural areas, the average Medicare utilization among hospitals that closed was 
65.6 percent compared to an average of 59 percent for all rural hospitals 
nationally.  About nine Medicare patients were in the hospital on an average day in 
the year prior to closure. 
In urban areas, the average Medicare utilization among hospitals that closed was 
40.5 percent compared to an average of 48 percent for all urban hospitals 
nationally.  About 19 Medicare patients were in the hospital on an average day in 
the year prior to closure. 
!	 Medicaid utilization in closed hospitals was lower than the national average for rural 
hospitals, and higher for urban hospitals. 
In rural areas, the average Medicaid utilization among hospitals that closed was 
7.2 percent as compared to an average of 12 percent for all hospitals nationally. 
In urban areas, the average Medicaid utilization among hospitals that closed was 
17.1 percent as compared to an average of 14 percent for all urban hospitals 
nationally. 
!	 No single factor or event caused hospitals to close.  Hospitals closed because of the 
interrelated factors of declining occupancy, lagging revenues, and rising costs.  Hospital 
viability depends on the stability of all three factors.  The weakening of any one of these 
factors may begin a chain reaction eventually leading to hospital closure. 
!	 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. 
!	 At the time of our inspection, 25 of the 38 closed hospital facilities (66 percent) were 
being used for health-related services.  Also, plans were being made to use 2 of the 
remaining 13 vacant hospitals for health-related services. 
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ii  T A B L E  O F  C O N T E N T S

PAGE 
EXECUTIVE SUMMARY 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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

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

Where They Were  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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

Reasons for Hospital Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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

How Many Patients Were Affected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

What Inpatient Care and Emergency Services Are Available . . . . . . . . . . . . . . . .  8

What the Building Is Used for Now  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

APPENDICES 
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Number of Hospital Closures by State  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

Hospital Closures by Hospital Name and Location . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1
 I N T R O D U C T I O N

PURPOSE 
To describe the extent, characteristics, reasons for, and impact of hospital closure in 1997. 
BACKGROUND 
In the past, closure of general, acute care hospitals has generated public and congressional 
concern.  Numerous questions had 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. 
In response to these concerns, 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 on hospital closures in 1988 through 1994 showed a downward trend in the 
number of closures.  In 1995 and 1996, hospital closures more than doubled that of 1994, but 
were still less than in any other year since we began this series of reports. 
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1  The findings from the 1987 through 1996 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 1997. 
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:  A facility that stopped providing general, short-term, acute inpatient services in 
1997.  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 1997 in the same physical plant, it was not considered a closure. 
METHODOLOGY 
To determine the extent, reasons for, 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, including those that closed in 
1997 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 
President's Council on Integrity and Efficiency. 
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2  F I N D I N G S

Our analysis shows that: 
!	 Thirty-eight general, short-term, acute care hospitals closed in 1997 -- 0.8 percent of all 
hospitals. 
!	 One more hospital closed in 1997 than closed in each of the previous two years.  The 
characteristics, reasons for, and impact of closures were similar. 
!  Most hospitals that closed were small and had low occupancy rates. 
!	 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 Closed 
In 1997, there were 4,805 general, short-term, acute care hospitals in the United States entered on 
HCFA's data base as participating in the Medicare program.  Thirty-eight  hospitals closed in 
1997 -- 0.8 percent of all hospitals nationally. 
HOSPITALS IN THE U.S.:  4,805 
CLOSED IN 1997:  38 (0.8%) 
Closure of the 38 general, acute care hospitals reduced inpatient bed supply by 3,882 beds, or 0.5 
percent.  While 38 hospitals closed in 1997, 2 new hospitals opened, adding 204 beds.  In 
addition, 1 previously closed hospital reopened in 1997, adding another 37 beds. 
Where They Were 
The closed hospitals were located in 22 States.  California had the greatest number of closures 
(6), followed by Texas (4), Florida (3), Michigan (3), Virginia (3), Georgia (2), and Montana (2). 
The remaining 15 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. 
A higher percentage of urban hospitals (1.1%) closed in 1997 than did rural hospitals (0.5%). 
URBAN  RURAL 
HOSPITALS IN THE U.S.:  2,666  2,139 
CLOSED IN 1997: 28 (1.1%)  10 (0.5%)
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3  What The Closed Hospitals Were Like 
Size:  Both rural and urban hospitals that closed in 1997 were smaller, on average, than the 
national average size.  The average number of beds for hospitals nationwide is 154.  About 90 
percent of the hospitals that closed had fewer beds than the national average.  Moreover, half (50 
percent) of the hospitals that closed had fewer than 100 beds.  In contrast, 10 percent of the 
closed hospitals had more beds than the national average. 
SIZE OF CLOSED HOSPITALS 
Number of Closed Hospitals 
Rural  Urban  Total 
Number of Beds 
0 - 30  5  3  8 (21%) 
31 - 50  1  2  3 (8%) 
51 - 100  3  5  8 (21%) 
101 - 150  1  14  15 (40%) 
151 - 200  0  0  0 
201 - 300  0  2  2 (5%) 
301 >  0  2  2 (5%) 
Totals  10  28  38 
Rural hospitals that closed had an average of 47.9 beds as compared to an average of 68.2 beds 
for all rural hospitals nationally.  Urban hospitals that closed had an average of 121.5 beds as 
compared to an average of 222 beds for all urban hospitals nationally. 
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4  Occupancy:  Occupancy rates for closed rural and urban hospitals were lower on average than 
the national averages.1 
Rural hospitals that closed had an average occupancy rate of 26.9 percent as compared to an 
average of 32 percent for all rural hospitals nationally.  The average daily census in the year prior 
to closure was about 13 patients. 
Urban hospitals that closed had an average occupancy rate of 38.8 percent as compared to an 
average of 48 percent for all urban hospitals nationally.  The average daily census in the year prior 
to closure was about 47 patients. 
Medicare Utilization: The average Medicare utilization among rural hospitals that closed was 
higher than the national average.  The average Medicare utilization among urban hospitals that 
closed was lower than the national average.2 
In rural areas, the average Medicare utilization among hospitals that closed was 65.6 percent 
compared to an average of 59 percent for all rural hospitals nationally.  About nine Medicare 
patients were in the hospital on an average day in the year prior to closure. 
In urban areas, the average Medicare utilization among hospitals that closed was 40.5 percent 
compared to an average of 48 percent for all urban hospitals nationally.  About 19 Medicare 
patients were in the hospital on an average day in the year prior to closure. 
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 in closed 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. 
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5  Medicaid Utilization: The average Medicaid utilization among rural hospitals that closed was 
lower than the national average.  The average Medicaid utilization among urban hospitals that 
closed was higher than the national average.3 
In rural areas, the average Medicaid utilization among hospitals that closed was 7.2 percent as 
compared to an average of 12 percent for all hospitals nationally. 
In urban areas, the average Medicaid utilization among hospitals that closed was 17.1 percent as 
compared to an average of 14 percent for all urban hospitals nationally. 
3 Medicaid utilization is calculated in the same way as Medicare utilization. 
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6  REASONS FOR HOSPITAL CLOSURE 
As in our previous hospital closure studies, the many health care professionals interviewed 
reported no single reason for hospital closure.  Hospitals closed because of the interrelated factors 
of declining occupancy, lagging revenues, and rising costs.  Hospital viability was said to depend 
on the stability of all three factors.  The weakening of any one may begin a chain reaction 
eventually leading to hospital closure. 
Although the sequence and combination of these factors were not always the same, generally the 
scenario was the same as we reported in our 1996 Hospital Closure report: 
The hospitals occupancy begins to slide because a doctor leaves town or retires, or begins to 
admit patients to a more modern hospital not far away.  Lengths of stay are down because of 
prospective payment pressures and more effective treatment methods.  A new ambulatory surgical 
center has opened and is also drawing patients away. 
While occupancy is declining, the hospitals costs continue to rise.  Competition with other 
hospitals means that new, high technology equipment is needed.  Nurses and technicians are 
demanding higher salaries - and they are getting them from other hospitals nearby.  The building 
may be deteriorating but the hospital has not been able to fully fund its capital reserves for several 
years. 
On the other hand, patient care revenue is down because of lower occupancy and more uninsured 
or inadequately insured patients.  For those who do have coverage, either public or private, 
insurers are holding down their costs and further eroding the hospitals dwindling resources. 
Soon the hospital administrator is unable to manage the situation, and the Board examines its 
options: continue to go deeper into debt; sell the hospital; merge with another hospital; or close. 
The smaller the hospital, the less able it is to resist this downward spiral.  As noted earlier, the 
average size of the 38 hospitals that closed in 1997 was only 48 beds for rural hospitals and 122 
beds for urban hospitals.  They are considerably smaller than the national averages. 
IMPACT OF HOSPITAL CLOSURE 
In communities where hospitals closed in 1997, we determined the 
!  number of patients affected by closure of hospitals, 
!  availability of inpatient care and emergency medical services, and 
!  current use of closed hospital facilities. 
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7  How Many Patients Were Affected 
For rural hospitals that closed in 1997, the average daily census in the year prior to closure was 
about 13 patients.  The urban hospitals that closed had an average daily census of about 47 
patients. 
WHEN HOSPITALS CLOSED, 
HOW MANY PATIENTS WERE AFFECTED? 
Rural Hospitals  Urban Hospitals 
Average Number of Beds  47.9  121.5 
Average Occupancy Rate  x 26.9%  x 38.8% 
Average Number of Patients  12.9  47.1 
We analyzed Medicare utilization data to determine the number of elderly patients affected by 
hospital closure in 1997.  In rural hospitals that closed, about nine Medicare patients were in the 
hospital on an average day in the year prior to closure.  In the urban hospitals that closed, about 
19 Medicare patients were in the hospital on an average day. 
WHEN HOSPITALS CLOSED, 
HOW MANY MEDICARE PATIENTS WERE AFFECTED? 
Rural Hospitals  Urban Hospitals 
Average Patient Census  12.9  47.1 
Average Medicare Utilization Rate  x 65.6%  x 40.5% 
Average Number Medicare Patients  8.5  19.1 
What Inpatient Care and Emergency Services Are Available 
Inpatient Care:  In most communities where a hospital closed in 1997, inpatient hospital care 
was available nearby.4 
4 We assessed availability of inpatient medical care in miles from a closed hospital to the nearest inpatient 
facility. 
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8  NEAREST INPATIENT CARE TO CLOSED HOSPITALS 
NUMBER OF CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within 3 Miles  3 (30%)  18 (64%) 
4-10 Miles  1 (10%)  8 (29%) 
11-20 Miles  2 (20%)  2 (7%) 
21-30 Miles  2 (20%)  0 
More than 30 Miles  2 (20%)  0 
Totals  10 (100%)  28 (100%) 
Rural Areas:  Residents in 6 of the 10 rural communities (60 percent) where a hospital closed 
could get inpatient hospital care within 20 miles of the closed hospital.  Residents of Fort Benton, 
Montana and Malta, Montana had to travel 40 and 71 miles respectively for full service inpatient 
hospital care.  However, these frontier communities converted their closed hospitals into Medical 
Assistance Facilities (MAF).5  These MAF facilities provide up to four days of limited inpatient 
services. 
Urban Areas:  In 26 of the 28 urban communities (93%) where a hospital closed in 1997, 
residents could get inpatient hospital care within 10 miles of the closed hospital.  Residents in 22 
of the 28 urban communities (79 percent) where a hospital closed could get inpatient care in the 
same community. 
Emergency Services:  When a hospital closed, the community lost not only inpatient beds, but 
also 24-hour emergency services.6 
Rural Areas:  In 8 of the 10 rural communities (80 percent) where a hospital closed in 1997, 
emergency care facilities were available within 20 miles of the closed hospital.  Residents of 
Summerville, Georgia had to travel 23 miles for 24-hour emergency care and residents of Albany, 
Texas had to travel 30 miles for 24-hour emergency care. 
Urban Areas: Emergency care facilities were available within 10 miles of the closed hospital in all 
but one of the 28 urban communities where a hospital closed in 1997. Residents of Graysville, 
Alabama had to travel 12 miles for 24-hour emergency care.  In 23 of the 28 urban communities 
(82 percent) where a hospital closed, residents could get emergency services in the same town. 
5 The 1997 Balanced Budget Act changed Medical Assistance Facilities (MAF) to Critical Access Hospitals 
(CAH) as part of the Rural Hospital Flexibility Program. 
6 We assessed availability of emergency medical care in miles from a closed hospital to the nearest emergency 
facility. 
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9  NEAREST EMERGENCY SERVICES TO CLOSED HOSPITALS 
NUMBER OF CLOSED 
HOSPITALS 
DISTANCE  Rural  Urban 
Within 3 Miles  5 (50%)  19 (68%) 
4-10 Miles  1 (10%)  8 ( 28.5%) 
11-20 Miles  2 (20%)  1 (3.5%) 
21-30 Miles  2 (20%)  0 
More than 30 Miles  0  0 
Totals  10 (100%)  28 (100%) 
What the Building Is Used For Now 
At the time of our inspection, 25 of the 38 closed hospital facilities (66 percent) were being used 
for health-related services.  For example: 
!	 Healtheast Midway Hospital in St. Paul Minnesota and Stanislaus Medical Center in 
Modesto, California became outpatient care centers. 
!	 Chattooga County Hospital in Summerville, Georgia and Medcenter One Hospital in 
Mandan, North Dakota are now long-term care facilities. 
!	 Promina Windy Hill Hospital in Marietta, Georgia was converted to a long-term acute 
care hospital.  The newly converted facility also provides outpatient surgery. 
!	 Memorial Hospital of Michigan City, Indiana and Genesys Regional Medical Center-St. 
Joseph Campus in Flint, Michigan became specialty hospitals. 
!	 Loudoun Hospital Center in Leesburg, Virginia closed its short-term, acute inpatient care 
services at one facility and opened a new facility six miles away.  The former facility still 
provides long-term care and mental health services. 
!	 Phillips County Hospital in Malta, Montana and Missouri River Medical Center in Fort 
Benton, Montana were converted to HCFA sponsored Medical Assistance Facilities.  In 
addition to providing limited inpatient care, they provide 24-hour emergency services and 
outpatient care.  (The Office of Inspector General released a report on Medical Assistance 
Facilities (OEI-04-92-00731) in July 1993. 
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10  A P P E N D I X  A

METHODOLOGY 
Extent of Hospital Closure 
To determine how many hospitals closed in 1997, we contacted 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 1997.  When a 
closed hospital met the study's definition or when there were questions, we surveyed 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 Medicare's Prospective Payment System (PPS) in the universe.  There were 
4,805 hospitals listed on HCRIS as short-term, acute care, general hospitals for the thirteenth year 
of PPS (PPS 13). 
Characteristics of Hospital Closure 
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 1997 and its accounting year was 
on a January-December cycle, we used the provider's January 1, 1996 to December 31, 1996 
report. 
Reasons for and Impact of Hospital Closure 
We limited our "impact" analysis to the distance from a closed hospital to the nearest still-
operating hospitals and to emergency services.  In addition to the HCRIS, 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 
!  State certification and licensing agencies 
!  State hospital associations 
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A - 1  A P P E N D I X  B

1997 HOSPITAL CLOSURES - RANKED BY STATE 
State  Total Closures  Rural Closures  Urban Closures 
California  6  0  6 
Texas  4  1  3 
Florida  3  0  3 
Michigan  3  0  3 
Virginia  3  0  3 
Georgia  2  1  1 
Montana  2  2  0 
Alabama  1  0  1 
Illinois  1  1  0 
Indiana  1  1  0 
Kentucky  1  1  0 
Minnesota  1  0  1 
Missouri  1  0  1 
North Dakota  1  0  1 
New Jersey  1  0  1 
New York  1  0  1 
Ohio  1  0  1 
Pennsylvania  1  0  1 
South Carolina  1  1  0 
Tennessee  1  1  0 
Utah  1  0  1 
West Virginia  1  1  0 
22 States  38 Closures  10 Rural  28 Urban 
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B - 1
 A P P E N D I X  C

1997 HOSPITAL CLOSURES BY NAME AND LOCATION 
Rural/ 
Hospital Name  City  State  Urban 
Longview General Hospital  Graysville  AL  urban 
Newhall Community Hospital  Newhall  CA  urban 
East Bay Hospital  Richmond  CA  urban 
Harbor View Medical Center  San Diego  CA  urban 
Pioneer Hospital  Artesia  CA  urban 
Stanislaus Medical Center  Modesto  CA  urban 
Thompson Memorial Medical Center  Burbank  CA  urban 
Parkway West Regional Medical Center  Miami  FL  urban 
University General Hospital  Seminole  FL  urban 
Columbia Pompano Beach Medical Center  Pompano Beach  FL  urban 
Chattooga County Hospital  Summerville  GA  rural 
Promina Windy Hill Hospital  Marietta  GA  urban 
Central Community Hospital  Clifton  IL  rural 
Memorial Hospital of Michigan City  Michigan City  IN  rural 
McLean County General Hospital  Calhoun  KY  rural 
Thorn Hospital  Hudson  MI  urban 
Genesys Regional Med Ctr-St. Joseph  Flint  MI  urban 
Genesys Regional Med Ctr-Flint  Flint  MI  urban 
Healtheast Midway Hospital  St. Paul  MN  urban 
Columbia Hospital-North Campus  Springfield  MO  urban 
Missouri River Medical Center  Fort Benton  MT  rural 
Phillips County Hospital  Malta  MT  rural 
Medcenter One Mandan  Mandan  ND  urban 
United Hospitals Medical Center  Newark  NJ  urban 
Union Hospital of the Bronx  Bronx  NY  urban 
Mercy Hospital  Toledo  OH  urban 
Mt. Sinai Hospital  Philadelphia  PA  urban 
Mullins Hospital  Mullins  SC  rural 
Baptist Hospital of Roane County  Rockwood  TN  rural 
Columbia Doctors Hospital East Loop  Houston  TX  urban 
Columbia Medical Arts Hospital  Texarkana  TX  urban 
Shackelford County Hospital District  Albany  TX  rural 
South Park Hospital  Lubbock  TX  urban 
Paracelsus Regional Hospital and Med Ctr  South Salt Lake City  UT  urban 
Loudoun Hospital Center  Leesburg  VA  urban 
Portsmith General Hospital  Portsmith  VA  urban 
Newport News General Hospital  Newport News  VA  urban 
Beckley  Hospital  Beckley  WV  rural 
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C - 1