Case Studies

Despite widespread acknowledgment of waste and inefficiency in the U.S. health care system, there have not been dramatic breakthroughs that point the way to more cost-effective alternatives. The problems that contribute to high costs and mediocre quality are complex and intertwined with the organization and financing of health services. There are, however, changes under way within leading organizations that suggest significant improvements in quality and value can be achieved. In 2008, the Leapfrog Group's Hospital Recognition Program began identifying hospitals that have made "big leaps in health care safety, quality, and customer value." Thirteen hospitals out of nearly 1,300 who voluntarily submitted data in 2008 achieved top scores in quality of care while keeping resource use low. To learn what opportunities exist for all hospitals to achieve greater efficiency, we conducted case studies of four of the 13 Leapfrog Group-designated "Highest Value Hospitals." These included Fairview Southdale Hospital in Edina, Minn., North Mississippi Medical Center in Tupelo, Miss., Park Nicollet Methodist Hospital in St. Louis Park, Minn., and Providence St. Vincent Medical Center in Portland, Ore. This paper offers a synthesis of lessons from their experiences.  â€” View Case Study

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.  â€” View Case Study

This private hospital has a designated team, known as the Vascular Access Specialist Team, comprising about 10 registered nurses who have a minimum of two years of nursing experience and are specially trained in central line insertion techniques, ultrasound guidance, and Centers for Disease Control and Preventioninfection prevention guidelines.  â€” 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.  â€” 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.  â€” 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.  â€” View Case Study

This report synthesizes lessons from four hospitals that reported they did not experience any central line-associated bloodstream infections in their intensive care units in 2009. Lessons include: the importance of following evidencebased protocols to prevent infection; the need for dedicated teams to oversee all central line insertions; the value of participation in statewide, national, or regional CLABSI collaboratives or initiatives; and the necessity for close monitoring of infection rates, giving feedback to staff, and applying internal and external goals. The report also presents ways these hospitals are spreading prevention techniques to non-ICU units, and strategies for preventing other health care-associated infections.  â€” View Case Study

This nonprofit teaching hospital relies on intensivists to provide ICU caare. As part of their efforts to improve care, the intensivists recommended use of an evidence-based CLABSI prevention protocol that includes the use of a checklist to promote compliance. To ensure the protocol was followed, the hospital trained and empowered nurses to enforce standards during the placement process and restricted the number and type of hospital personnel permitted to insert lines.  â€” View Case Study

Fairview Southdale Hospital was recognized as one of 13 "Highest Value Hospitals" by the Leapfrog Group in 2008, based on efficiency scores that took into account quality of care as well as resource utilization. The hospital, which was selected from nearly 1,300 hospitals that had voluntarily submitted data, received a top efficiency score for all four conditions/procedures examined: coronary artery bypass graft, percutaneous coronary interventions, treatment of acute myocardial infarction, and pneumonia care.  â€” 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.  â€” 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.  â€” 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.  â€” 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  â€” 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.  â€” 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.  â€” 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.  â€” 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.  â€” View Case Study

McKay-Dee Hospital Center in Ogden, Utah, part of the Intermountain Healthcare System, had readmission rates in the lowest 3 percent of hospitals across the nation for all three clinical areas reported to the Centers for Medicare and Medicaid Services (CMS) for the selection period, and its heart failure and pneumonia readmission rates were within the best 1 percent of hospitals reporting.  â€” View Case Study

Johns Hopkins Medicine—an academic medical center and nonprofit integrated health care delivery system—set a goal in 2002 of making its care the safest in the world. The Comprehensive Unit-Based Safety Program, which trains frontline teams to identify and mitigate patient safety hazards, is a key strategy. The model has been spread to hospitals nationwide and was associated with reductions in central line–associated bloodstream infections in intensive care units. Through its safety efforts, Hopkins has achieved improvements in safety practices such as increased hand-washing, in patient outcomes such as fewer pressure ulcers among patients, and in the hospital staff’s perceptions of the organizational safety culture. Safety principles have been spread outside the hospital setting to the system’s home care group. Success factors include setting ambitious goals, empowering frontline staff to make improvements, involving executives and the board in change, and rigorously measuring and holding units accountable for results.  â€” 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.  â€” View Case Study