Case Studies

Four case studies--of the Department of Veterans Affairs, Sentara Healthcare, OSF HealthCare, and Johns Hopkins Medicine--document the progress achieved in the past five years by health care organizations that were early leaders in patient safety improvement. Their experience reflects an expansion of interventions from individual hospital units to whole facilities and delivery systems, including new settings such as home health care. Approaches include developing practical methods for training, coaching, and motivating staff to engage in patient safety work; designing effective tools and systems to minimize error and maximize learning; and leading change by setting ambitious goals, measuring and holding units accountable for performance, and sharing stories to convey values. Results include advancements in safety practices, reductions in serious events of patient harm, improved organizational safety climate and morale, and declines in malpractice claims. Keeping the commitment to patient safety has required sustained focus on making safety a core organizational value, a willingness to innovate and adapt, and perseverance in pursuing goals.  — 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

Memorial Hermann Memorial City Medical Center, in Houston, Texas, achieved superior readmission rates in two of the three clinical areas reported to the Centers for Medicare and Medicaid Services. Its readmission rate for patients with acute myocardial infarction and pneumonia surpassed the best 10 percent of hospitals in the country for the selection period. Its readmission rate for heart failure was not as strong, outperforming the national average only by a narrow margin.  — View Case Study

Mercy Medical Center in Cedar Rapids, Iowa, had readmission rates in the lowest 3 percent among U.S. hospitals in all three clinical areas—heart attack, heart failure, and pneumonia—reported to the Centers for Medicare and Medicaid Services for the selection period.  — 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

North Mississippi Medical Center (NMMC) in Tupelo, Mississippi, was designated a Highest Value Hospital in 2008 for achieving a top efficiency score (reflecting both the quality of care and resource use) from the Leapfrog Group for coronary artery bypass graft, percutaneous coronary interventions, and pneumonia care. Leaders at NMMC believe that by focusing on serving patients, empowering staff, and improving health care quality, lower costs and growth will naturally follow.  — 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

OSF HealthCare, an integrated health care delivery system serving parts of Illinois and Michigan, was an early leader in promoting a collaborative approach to patient safety improvement. OSF has enhanced these efforts during the past five years by continuing to build awareness of safety risks through systemwide error reporting and local risk assessment, by identifying clinicians who can serve as models for their peers, and by engaging staff in intraorganizational learning and competition to spur improvement. It also has raised performance expectations by educating hospital- and system-level board members about patient safety issues and quality improvement techniques. Exemplary facility-level results include: an 80 percent reduction over six years in the rate of ventilator-associated pneumonia among intensive care patients; an increase from 39 percent to 100 percent in compliance with a standardized medication administration process; and a nine-percentage-point increase over one year in surgical patients receiving evidence-based treatment to prevent infections.  — View Case Study

Park Nicollet Methodist Hospital (Methodist) is the single hospital of Park Nicollet Health Services, an integrated health care delivery system based in St. Louis Park, Minnesota. Approximately 96 percent of the hospital's admissions are patients served by the systems' integrated multispecialty group practice, which comprises 25 clinics in the West Metro section of Minneapolis. Methodist serves about 27,000 patients per year in a region that has been leading the country in health care quality and payment innovations.  — 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

At this nonprofit community hospital, nurses are assigned responsibility for monitoring adherence to the CLABSI prevention protocol, but all staff are encouraged to stop the central line insertion procedure if a lapse in protocol occurs. Per hospital procedure, staff also review daily whether continued use of a central line is necessary.  — View Case Study

Providence St. Vincent Medical Center was recognized by the Leapfrog Group as a "Highest Value Hospital" in 2008. But it was its pursuit of quality and accessibility, not efficiency, which appears to have been the driving force behind its success. The designation can be traced to three notable initiatives: its Safe Patient Access Capacity Enhancement (SPACE) project, the simplification of surgical orders, and the use of staff councils to address safety concerns.  — 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