Is Choosing a “Good” Hospital Like Choosing a “Good” High School?

Editors at U.S. News and World Report would answer yes to the question. Even though life and death haunt rankings of hospitals while decisions about high schools carry less momentous consequences, the magazine has created a market niche that bring in loads of cash to the company. In doing so, these ratings unintentionally (and unfortunately) converge with current policymakers’ yearning to make institutions more uniform and less complex, while reducing the diversity and flexibility of both schools and hospitals.

Magazine rating systems identify a wide range of criteria that medical and school experts use to judge quality, collect data on these criteria, sort the evidence, and rank in numerical order the best institutions in each category. Then the howling begins.

Those hospitals and high schools who move up the ranking ladder howl in joy; those that fall a few rungs, howl in anger. And those of us mystified by the process squirm. We wonder about the worth of magazine judgments when editors reduce the quality of hospital care and medical attention or the academic climate and classroom teaching to a number which in of itself is a result of squishing together other numbers.

Anyone over the age of 21 knows that any performance measure can be gamed. Judged on mortality rates, some hospitals avoid the sickest patients. Some high schools indirectly press low performing students to leave school. Knowing that any metric can be gamed leads those of us skeptical of rankings to scratch our heads and ask: Do such numbers mean anything in the real world where we do have to choose hospitals and high schools?

Again, the answer is yes. Middle- and upper-middle class consumers of medical care consider a hospital’s reputation, whether their illnesses match the reputed quality of the hospital, personal preferences, cost, and other reasons that may or may not correlate highly with best-hospital rankings. Educated patients and parents find these rankings helpful in making choices about “good” hospitals and high schools. They buy the magazine and pile up hundreds of thousands of hits on those website when annual rankings appear. Less informed working class and low-income consumers of medical care, however, lacking medical insurance, have little choice other than considering the closest emergency room.

Even though the reduction of quality and institutional complexity to what can be easily measured leads to frequent gaming by school and hospital officials to raise their rankings– that doesn’t bother me too much. What does bother me is how the definition of a “good” hospital or high school gets narrowed to what metrics are collected even though the range of definitions about “goodness” among people for each of these institutions vary a great deal.

What is “good” for one parent in choosing a high school is much less so for another. Sure, most parents want high schools to prepare their sons and daughters to get into college. Period. But there are also many parents who think a “good” high school is one where you can also learn skills that will lead to a well-paying job after graduation that won’t require someone to sit in classrooms for four more years. There are many parents that want schools where students learn by doing, provide service to the community, and where students and teachers work closely together in teams to solve problems while reconciling differences.

In short, there are other “good” schools that never get ranked because no metrics exist to capture their “goodness” or even if measures are around, they are not used for rankings. Not a startling insight, to be sure, but one that often gets lost in the rush to find short-cuts when information overload, multi-tasking, and just plain fatigue leave little time, much less, energy for parents (or patients) to make consequential decisions.

So what if those who do the rankings slide into solidifying a one-size-fits-all “good” hospital and high school, ignoring other definitions of “good” institutions? Rankings won’t go away; they appeal to wine lovers, car enthusiasts, parents, and patients; people see them as simple, time-saving tools. In a consumer-driven culture where everything gets converted into a commodity to be bought and sold, numerical rankings will persist.

Yet it needs to be said again and again that these rating systems, unfortunately, converge with the current standards-based testing and accountability systems in schools. Policymakers who thrive on standardization and simplicity rather than flexibility and complexity secretly love ratings for this reason. In a democratic society, however, where diversity in backgrounds and independent thinking are prized, even nourished, simplistic uniformity in a “good” institution is can destroy that diversity and thinking.