Brigham and Women's Hospital is a 777-bed nonprofit, teaching hospital located in Boston, Massachusetts. Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey show that it is a leading hospital nationally on measures of patient satisfaction. Since 2002, the hospital has followed three strategies to improve patient satisfaction: allocating significant new funding for quality measurement and process improvement work, including establishing a Center for Clinical Excellence; developing a management information system for hospital leaders that tracks patient and family experiences, along with other hospital performance indicators; and seeking to enhance patients' experiences by working with frontline staff, including implementing new recruitment, training, management, and improvement strategies.  — View Case Study

Carolinas Medical Center was established by the Charlotte-Mecklenberg County Public Authority in 1939 to meet the health care needs of Mecklenberg County residents, and opened its first hospital in 1940. Keeping pace with population growth, multiple facilities now continue the original mission to "care for all who come." High scores on process-of-care, or "core," measures distinguish the Carolinas Medical Center network hospitals as a group, and Carolinas Medical Center–University as the top performer among them. The network relies on multidisciplinary teams who are accountable to leadership for meeting goals; reviews and publicizes performance indicators across hospitals in its network; and redesigns care processes so that standards can be achieved as a matter of routine.  — View Case Study

Denver Health, a comprehensive and integrated medical system that is Colorado's largest health care safety-net provider, has a national reputation as a high-performance organization. Members of The Commonwealth Fund Commission on a High Performance Health System observed Denver Health during a site visit in March 2006, to assess its operation and determine whether it might serve as a model for other public and private health care systems around the country. The Commission concluded that Denver Health is indeed a "learning laboratory." It has succeeded at providing coordinated care to the community, promoting a culture of continuous quality improvement, adopting new technology and incorporating it into everyday practice, taking risks and making mid-course corrections, and providing leadership and support—and accepting accountability—both at the top and throughout the organization. Moreover, it has accomplished these objectives and others in straightforward ways that could be adapted elsewhere.  — View Case Study

Duke University Hospital is a 924-bed academic medical center in Durham, North Carolina. Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey show that it is a leading hospital nationally on measures of patient satisfaction. Duke University Hospital leaders say that ensuring patient satisfaction requires both organizational and tactical strategies. Particular strategies include: commitment to improving customer service and work culture, and to leadership training; use of a Balanced Scorecard management tool; use of Six Sigma improvement methodology to address underperformance; and recognition of staff members and units demonstrating outstanding customer service.  — View Case Study

Under the leadership of a quality-focused CEO, Flowers Hospital in Dothan, Ala., climbed from average to exemplary in Centers for Medicare and Medicaid Services (CMS) process-of-care, or "core" measures, across four clinical areas (heart attack, heart failure, pneumonia, and surgical infection prevention) in just two years.  — View Case Study

Adherence to evidence-based practice guidelines, perfomance benchmarking and feedback, multidisciplinary committees engaged in root-cause analysis, and strong leadership combined to produce near-perfect compliance with evidence-based process-of-care ("core") measures in four clinical areas at Gaston Memorial Hospital, near Charlotte, N.C.  — View Case Study

Geisinger Health System is a physician-led, not-for-profit, integrated delivery system serving an area with approximately 2.6 million people in northeastern and central Pennsylvania with innovative products and services designed to drive higher performance. Geisinger's leaders believe that the organization can simultaneously improve quality, satisfaction, and efficiency only by redesigning and reengineering the delivery of care. This philosophy is epitomized by ProvenCare, a portfolio of products (many of which are package-priced) for which care processes have been redesigned to reliably administer a coordinated bundle of evidence-based best practices. Use of the ProvenCare model has improved clinical outcomes while decreasing resource utilization. Fundamental to Geisinger's success are its vision of becoming a national model for care delivery, the leadership to achieve that vision reinforced with a performance-based compensation system strategically aligned with specific goals every year, and timely feedback using an advanced electronic health record to measure progress toward those goals.  — View Case Study

Gundersen Lutheran Health System is a physician-led, not-for-profit integrated delivery system serving more than 550,000 people in Wisconsin, Iowa, and Minnesota. Gundersen Lutheran has increased efficiency, improved patient care, and achieved the high performance associated with large urban institutions by: 1) using clinical and financial outcomes to set benchmarks and targets for improvement, to increase transparency, and to drive improvement among physicians; 2) investing in primary care and disease management programs; and 3) hiring engineers to improve operations. It offers leadership training programs that encourage cross-training and partnership within the institution and uses external collaborations to improve community health and extend its models of care and service to outlying communities. Gundersen Lutheran’s physician compact outlines the organization’s expectations of physicians and ensures that its medical staff remains committed to the organization’s mission: to distinguish itself in patient care, education, research, and community health  — View Case Study

HealthPartners is the nation's largest nonprofit, consumer-governed health care organization, providing health and dental care and coverage to more than 1 million individuals in Minnesota and surrounding states. Key factors driving HealthPartners' performance are a consumer-focused mission; a regional focus, scale, and scope integrating a broad range of services; strategic use of electronic health records to support care redesign; and a culture of continuous improvement. A comprehensive model for improvement includes setting ambitious targets for health system transformation; measuring what is important in order to optimize care; agreeing on best care practices and supporting improvement at the clinic level; aligning incentives with goals; and making results transparent internally and externally. HealthPartners' experience suggests that a nonprofit health plan market oriented to physician group practice--supported by collaborative measurement, improvement, and reporting structures--creates a community environment that helps each participant achieve objectives more effectively.  — View Case Study

Henry Ford Health System is a vertically integrated health care system in southeastern Michigan whose leadership is committed to systemic integration, clinical excellence, and customer value through the core competencies of collaboration, care coordination, and innovation and learning. Henry Ford’s care innovation initiatives are multidisciplinary, team-led projects that target improvements in quality measures and evidence-based standards through problem-solving and the identification of common metrics to build consensus. The collaborative approach, fostered by shared vision and values, facilitates transformation throughout the system. Moreover, Henry Ford’s integration of care delivery and coverage facilitates quality monitoring, measurement, and improvement activities.  — View Case Study

Holland Hospital has significantly improved its performance on the pneumonia process-of-care, or core measures, over the last five years. The core measures, developed by the Hospital Quality Alliance, relate to provision of recommended treatment in four clinical areas: heart attack, heart failure, pneumonia, and surgical care. Holland Hospital performs in at least the top 20 percent in all four areas, and particularly well in pneumonia and surgical care.  — View Case Study

Hutcheson Medical Center is a 179-bed community hospital located in Fort Oglethorpe, Georgia, eight miles southeast of Chattanooga, Tennessee. By focusing intently on patient-staff interactions and patients' needs, Hutcheson Medical Center has turned around its quality and financial indicators in the last two-and-a-half years. Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey show that Hutcheson is now a leading hospital nationally on measures of patient satisfaction. Five components of the hospital's strategy may be behind their success: fostering a culture of customer service; empowering nurses through shared governance; collecting and tracking data to chart progress; visibility of leaders; and implementing evidence-based practice.  — View Case Study

Kaiser Permanente--comprising the Kaiser Foundation Health Plan, Kaiser Foundation Hospitals, and Permanente Medical Groups in eight regions--is the largest nonprofit integrated health care delivery system in the United States. The successful evolution of this organizational structure in a competitive marketplace has required a close partnership between managers and physicians supported by a culture of physician group accountability for quality and efficiency. An overarching agenda for achieving excellence focuses on high-impact health conditions, provides goal-oriented tools to analyze population data, proactively identifies patients in need of intervention, supports systematic process improvements, and promotes collaboration between patients and professionals to improve health. Central to this effort is KP HealthConnect, a comprehensive health information system that integrates an electronic health record with the tools to support physicians in delivering evidence-based medicine, coupled with a robust online patient portal that enhances members’ access to and involvement in their care.  — View Case Study

Two hospitals in the Kettering Health Network--Kettering Medical Center and Sycamore Medical Center-- scored among the top 3 percent of U.S. hospitals on five surgical measures collected and reported by Centers for Medicare and Medicaid Services. The hospitals have made nurses key to their improvement strategy. In addition, they have focused on national quality initiatives, such as achieving Nursing Magnet status and the Malcolm Baldrige National Quality Award. The biggest change at the two hospitals in recent years was the introduction of concurrent quality monitoring and feedback to providers and managers. The use of real-time data has inspired competition and greater accountability among physicians and nurses, resulting in near-perfect compliance with recommended surgical processes.  — View Case Study

Exemplary quality scores at Luther Midelfort Mayo Health System in Eau Claire, Wis., are the result of a long-term commitment to building quality and safety into systems of care. Since joining the Mayo Health System in 1992, Luther Midelfort has advanced a culture that supports staff in their efforts to test new ideas and improve care. Although work focused on Centers for Medicare and Medicaid Services (CMS) core measures began recently, the newer efforts follow the philosophy and strategy established years earlier. In a recent analysis by The Commonwealth Fund, Luther Midelfort achieved the third-highest score in the country on a composite of 22 process-of-care measures that all hospitals report to CMS.  — View Case Study

Marshfield Clinic is a not-for-profit, physician-governed multispecialty group practice serving residents of rural Wisconsin through a regional ambulatory care system, an affiliated health plan, and related foundations supporting health research and education. Marshfield has engaged its physicians and staff in a program of clinical performance improvement aimed at enhancing patient access, coordination of care, and efficiency of clinical operations. An internally developed electronic health record acts as a care planning tool for delivering preventive care and managing chronic diseases. A telemedicine network expands access to care for patients living in rural and remote areas. Marshfield Clinic’s experience shows how an organized group of physicians can improve patient outcomes and reduce costs by undertaking a population-based approach to ambulatory care management supported by robust information technology. It also suggests that group-level performance incentives that are aligned with an organization's strategic goals have the potential to enhance population health management.  — View Case Study

The Mayo Clinic is the world’s oldest and largest integrated multispecialty group medical practice, combining clinical practice, education, and research at the regional, national, and international levels for the benefit of individuals with routine as well as complex health care needs. Mayo’s model of integrated care is one of multidisciplinary practice with salary-based compensation that fosters team-oriented patient care and peer accountability, a supportive infrastructure allowing physicians and other caregivers to excel at clinical work, and a physician-led governance structure promoting a patient-centered culture. Full integration of the hospital and clinic and the use of a shared electronic medical record across inpatient and outpatient settings also have been critical to realizing efficiencies and promoting clinical excellence. Mayo fosters a learning environment in which teams of medical professionals use information technology and systems engineering to learn from each other and improve care in tandem with clinical practice.  — View Case Study

Memorial Healthcare System (MHS) has provided public hospital care in South Broward County, Florida, for 56 years. MHS hospitals scored very well on process-of-care measures, not only compared with other publicly owned hospitals but compared with all hospitals. MHS leaders have developed a multifaceted quality and safety strategy that relies on storytelling to convey to staff and patients the type of care they wish to provide. Monitoring and reporting of performance data, combined with careful design of care processes, help the hospital achieve its goals. Staff also receive training and coaching on ways to enhance the quality of care. In addition, hospital leaders’ desire to appeal to privately insured patients, and to keep people healthy before and after hospitalizations, appears to drive improvement. For further information about the public hospital selection process and cross-cutting lessons about their improvement efforts, please see our introduction to the public hospital case study series.  — View Case Study

Munson Medical Center is a 391-bed, nonprofit hospital located in Traverse City, Michigan. By focusing on patient satisfaction and engaging frontline staff in improving care, it has become one of the better large hospitals in the United States in terms of overall patient satisfaction, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The following strategies appear to contribute to the hospital's success: ongoing measurement and feedback; high nurse-to-patient ratios, greater nurse authority under the "shared governance" model; acuity-adaptable patient rooms; mandated quiet time and staff relaxation rooms; and shift-to-shift bedside reports.  — View Case Study

This case study focuses on Norman Regional Health System's achievement in providing recommended treatment on process-of-care, or "core," measures. Nearly a decade ago, Norman’s Board chair and a top physician administrator became champions for quality improvement, motivated by the fact that Norman had achieved just average scores on quality measures. Organizational, cultural, and system changes at Norman Regional, including the development of order sets and care plans, performance data transparency, concurrent review for certain patient groups, as well as a pharmacist-driven intervention, have led to sustained progress. For further information about the public hospital selection process and cross-cutting lessons about their improvement efforts, please see our introduction to the public hospital case study series.  — View Case Study

In 2007, NorthShore University Health System achieved 97 percent compliance with Centers for Medicare and Medicaid Services (CMS) process-of-care measures, a 12-point increase from just one year before. With high-level endorsement, NorthShore pursued the following improvement strategies: a system-wide staff education initiative led by the quality department, including the essential engagement of medical staff, pharmacists, and nurses; promoting physician buy-in by encouraging them to contact CMS with questions about the care standards; use of an electronic health record (EHR) system as a tool in education, care management, and performance tracking; and use of real-time data for concurrent review of patient care, made possible by exporting data from the EHR.  — View Case Study

Since 2002, Oklahoma Heart Hospital has consistently demonstrated high adherence to process-of-care or "core" measures and high patient satisfaction. Key strategies behind their excellent scores include: physician leaders' commitment to quality; physician offices housed within the hospital, providing greater access to nurses and patients; flat organizational structure that allows quick implementation of operational changes; highly experienced nurses and high nurse-to-patient ratios; and more.  — View Case Study

Parkview Medical Center is one of the top-performing hospitals in the country in the pneumonia process-of-care measures, or "core," measures. Hospital leaders credit the organization's strong performance in pneumonia care to the regular communication and reinforcement provided by quality improvement staff. Concurrent review in particular is relied on as an opportunity to provide real-time education and reminders to providers at the point of care. Those interviewed also emphasize that the hospital leaders are willing to try anything in the name of improving patient care.  — View Case Study

Eighty-seven percent of patients recently discharged from Parkwest Medical Center said they would recommend the hospital to a family member or friend-a patient satisfaction level 19 percentage points higher than the national average. Parkwest has focused on hiring and supporting staff who subscribe to its vision of providing excellent patient care and sharing responsibility for doing so. The hospital's goals for quality care and patient satisfaction are spread through the Leadership Evaluation Module, through which the performance goals and standards for administrators, managers, and staff are aligned and managers are held responsible for the performance of the staff who report to them. Performance-based rewards and recognition help to reinforce the standards.  — View Case Study

Compared with other hospitals, public hospitals are generally assumed to face multiple barriers to providing high-quality care: lower revenues; sicker patients who may have infrequent contact with the health care system; and an older infrastructure, particularly related to health information technology. This case study series set out to find how some public hospitals have succeeded in achieving excellence in quality of care, in spite of such challenges. We sought to understand the strategies and factors that contribute to high performance, as well as the barriers and challenges public hospitals face. To do so, researchers examined aggregate quality scores on 23 process-of-care measures reported by CMS, for all hospitals submitting data from July 2007 through June 2008. They selected for case study analysis eight public hospitals from among 14 that performed among the top 10 percent of more than 2,000 public and private hospitals reporting during this period.  — View Case Study