Turnover among hospital CEOs was 18 percent in 2016, the same as in the prior two years, but remains among “the highest rates calculated in the last two decades,” according to the American College of Healthcare Executives (ACHE).

The ACHE survey results were below the record high of 20 percent in 2013, and the rate has been in the double-digits dating back to 1981. At the same time, there’s been a steady decline in the number of hospitals, hovering around 50 fewer hospitals each year since 2012, down to 4,401 in the most recent survey, with elevated rates of CEO turnover becoming “the norm” in the industry.

“The ongoing consolidation of healthcare organizations, continuing movement toward new models of care and retiring leaders from the baby boomer era may all be influencing these turnover rates,” ACHE President and CEO Deborah Bowen said in a statement.

Historically, the 18 percent CEO turnover trend mirrors similar numbers from 1987 and 88. The all-time low was 13 percent, seen in both 1983 and 1990.

State-by-state numbers vary wildly. The District of Columbia had the highest adjusted CEO turnover rate by far, at 67 percent, well ahead of second-ranked New Hampshire’s 38 percent. Washington (30 percent), Vermont (29 percent) and Georgia (27 percent) rounded out the top five.

At the other end of the spectrum, Delaware (2 percent), North Dakota (7 percent) and Alaska (9 percent) had the lowest rates of turnover among its hospital leaders.

With changes in leadership being so common and frequent, Bowen said it’s imperative hospital and health systems have plans in place to quickly fill vacant executive roles.

“Succession planning should include not only naming and preparing immediate successors to C-suite positions, but more broadly an emphasis on developing the pipeline of future leaders,” she said.