Case Study High-Performing Health Care Organization • December 2008 Flowers Hospital: Nearing Perfection on Core Measures J ennifer E dwards , D r.P.H. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance health care system. The Fund carries Location: Dothan, Ala., near Georgia and Florida borders out this mandate by supporting Type: Nonteaching, for-profit community hospital owned by Community Health Systems, Inc., of independent research on health care Franklin, Tenn. issues and making grants to improve Beds: 235 health care practice and policy. Distinction: Top 1 percent of hospitals in composite of 22 process-of-care quality measures among roughly 2,000 hospitals (about half of U.S. acute-care hospitals) eligible for this analysis; also scored in top 1 percent of hospitals for prevention of surgical infections. Timeframe: Second quarter of 2006 through first quarter of 2007. To be included, hospitals must have submitted data to the Centers for Medicare and Medicaid Services for all 22 measures, with a minimum of 30 cases for at least one measure in each of four clinical areas. See Appendix A for full methodology.      For more information about this study, Summary please contact: Under the leadership of a quality-focused CEO, Flowers Hospital in Dothan, Jennifer Edwards, Dr.P.H. Health Management Associates Ala., climbed from average to exemplary in Centers for Medicare and Medicaid jedwards@healthmanagement.com 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. Flowers’ Quality Department identifies patients in these clinical areas early in their hospital stay and continuously monitors their progress to ensure they are getting the right care—a unique approach to achieving high performance. This approach has five critical elements: To download this publication and • Patient identification. Patients who experience heart failure, heart learn about others as they become available, visit us online at attack, pneumonia, or have surgery are identified at the beginning of www.commonwealthfund.org and their hospitalization, so that appropriate care can be provided in a register to receive Fund e-Alerts. timely manner. Commonwealth Fund pub. 1193 Vol. 1 2T he  C ommonwealth F und • Concurrent review. A concurrent nurse Strategies for Success reviewer monitors each eligible patient to In 2005, Flowers’ scores on the CMS core measures ensure his or her care meets the standards and were in the 85 to 90 percent range—good, but leaving intervenes as needed. room for improvement. Like many hospitals, Flowers • Tools for frontline staff. Nurses receive a first used retrospective data to analyze why some color-coded packet to help them follow the patients were not getting care that met CMS standards. expected practices, including providing patient The data led them to test numerous system changes education and delivering the appropriate care and reporting methods. “But the flaw to our old sys- for that condition. Disease-specific progress tem of review,” according to Chief Quality Officer notes and order forms are also used. Amy Butler, R.N., CCRN, “was by the time the data were reviewed and understood, the patient had been • Quality improvement teams. discharged and there was no chance to improve that Multidisciplinary teams review all failures of patient’s experience.” To improve performance, Flowers compliance and modify care processes if neces- created a system to allow much more timely review. sary to improve future adherence to guidelines. CEO Keith Granger envisioned Flowers as a top- • Performance oversight and accountability. performing hospital and helped to lead its transformation. Team leaders meet with the CEO to discuss “fall outs,” establishing accountability for Patient Identification achieving goals among the staff at the The CMS core measures pertain to patients with heart highest levels. failure, heart attack, pneumonia, or those at risk for surgical infection. In addition, Flowers has prioritized In 2007, Flowers Hospital achieved 99.7 per- the care of pediatric asthma patients. Identifying these cent compliance with CMS core measures, the second- patients as target groups, or panels, is a critical compo- highest score in the country. Now staff members are nent of the hospital’s quality strategy. testing whether the same strategy of making mid-stay Surgical patients are, of course, easy to identify corrections can help the hospital improve its patient because they are nearly always admitted to the hospital satisfaction scores on the Hospital Consumer for surgery. For such patients, the responsibility for Assessment of Healthcare Providers and Systems monitoring achievement of standards to prevent surgical (HCAHPS) survey. infections is universal, and begins with the operating room staff. Heart attack patients are also easily identified. Organization Heart failure and pneumonia patients are harder Flowers Hospital sits in a rural part of Alabama, close to flag because their admitting diagnoses are often to the Georgia and Florida borders, and serves as a something other than these two conditions. At Flowers, referral hospital for the region. It has 235 licensed new admissions are reviewed for likely cases of heart beds but runs a census of about 160 patients a day. Its failure or pneumonia. In addition, a report from the largest payer is Medicare, followed by Blue Cross, but Information Technology (IT) Department identifies the hospital gets its share of self-pay patients as well. newly admitted patients who have a prior admission of A non-teaching, community hospital, Flowers was heart failure, and patients are asked about a history of recently purchased by Community Health Systems of heart failure during their intake interview. Franklin, Tenn. Retrospective review showed that these screens helped, but the hospital was still missing about 30 to 50 new heart failure patients per month. A large per- centage of those missed turned out to be renal patients. This realization led staff to screen all renal patients for F lowers H ospital : N earing P erfection on C ore M easures 3 inclusion in the heart failure panel. A further identifi- steps nurses should take in applying the protocol, and cation strategy is an enzyme test to assess a patient’s additional tracking information. A brightly colored BNP level, the amount of B-type natriuretic peptide in label placed on a chart identifies a patient’s condition the bloodstream. Patients whose BNP level exceeded and indicates the schedule of care nurses must provide. 100 pg/mL are likely to be experiencing heart failure, The label itself becomes a checklist, so the floor nurse so the lab system identifies all patients with a BNP and the concurrent reviewer know at a glance if care is level greater than 100. on course. Another tool is a physician-designed progress “The flaw to our old system of review was by the note for heart attack and heart failure patients time the data were reviewed and understood, the (Appendix B). This was developed in response to the patient had been discharged and there was no realization that, in some cases, care protocols for these chance to improve that patient’s experience.” patients appeared to have been missed, when in fact Amy Butler, R.N., CCRN, Chief Quality Officer certain patients should have been noted as being exempt from the care standard. Heart attack patients with an aspirin allergy, for example, appeared to be Concurrent Review out of compliance with the recommendation to provide The job of the concurrent reviewer is to monitor care aspirin upon arrival, since doctors were not adequately for all patients on the targeted panels. In reading documenting the exemption. The heart failure team patients’ charts, the reviewer may find reasons why a created a progress note on which physicians check off patient is not a candidate for care as recommended by relevant exclusions, and staff report that it has been the core measures and exclude these patients from easy to use and monitor. review. While making daily rounds on all remaining Pre-printed orders are also in use at Flowers, patients, the reviewer checks the chart against each helping to achieve greater uniformity in care pro- care standard—a task facilitated by the checklist labels cesses. Patients admitted for surgery, for example, described below—and intervenes to keep their care on have standing orders to start and stop appropriate anti- course. If, for example, a patient appears to be likely biotics. Physicians check off the right drugs and doses. to miss a dose of antibiotic, the concurrent reviewer can prompt the nurse or doctor to give the drug or write Quality Improvement Teams the prescription needed to keep the patient up to date. Flowers has an interdisciplinary quality improvement Flowers has one full-time concurrent reviewer team for each of the five targeted conditions. The and a small team of backup staff. One operating room teams are led by nurses and include other clinicians, staff member performs reviews on surgical cases. such as pharmacists and anesthesiologists. At biweekly meetings, the teams review data on compliance with Tools for Frontline Staff the CMS standards. Failures are discussed and root Like many hospitals, Flowers found that frontline staff causes identified. When needed, the teams redesign need more than just the guidance of a good protocol to care processes to ensure similar patients are not missed keep a patient’s care on course. Most staff know and in the future, using a rapid-cycle improvement meth- follow care protocols. However, Butler says, she was odology that has proven successful. “worried about the new nurse in the middle of the An example of a recent improvement developed night who may be less familiar with the protocol and by the surgical infection prevention team is the addi- her role.” Quality improvement teams developed pack- tion of a note on the medication administration record. ets (using different colors for each condition) describ- Data showed that some patients at risk of post-surgical ing the CMS standards. The packets contain patient infections did not have their antibiotics discontinued in education material, the care pathway, which delineates 4T he  C ommonwealth F und Medication Reconciliation Medication reconciliation is one of the hardest processes for a hospital to get right, but it is an important measure of patient safety. The Joint Commission added medication reconciliation to its accreditation review in 2007. Both heart attack and heart failure patients should be prescribed medication at discharge. Flowers Hospital found that, even when it achieved near-perfect compliance on other measures of care for these patients, documentation of the discharge medication was difficult to achieve because its medication reconciliation process was incomplete. The heart failure team came up with a potential solution. Upon admission, patients are asked to report all medications they are currently taking. The pharmacy department then enters these medications into a patient’s profile and indicates whether they are to be continued or held. Throughout the hospital stay, additional prescriptions are added to the medication administration record. Each night, the pharmacy generates an electronic medication discharge form; physicians review the form and note which drugs to continue and which to stop at discharge. The form can also be used as a prescription for any new drugs that need to be purchased post-discharge. Flowers does not currently have the capacity to store the information for future admissions or outpatient visits. However, later this year, they plan to implement an electronic health record that will support ongoing medication reconciliation across visits and sites of care. a timely manner after surgery. To ensure nurses stop Results the antibiotics at the right interval, the concurrent The results of this quality improvement approach have reviewer now puts a purple reminder note on the record; been dramatic. As of the end of 2007, Flowers this change has led to a nearly perfect compliance rate. Hospital was achieving exemplary performance across all core measures and holding the gains (Table, page 6). Performance Oversight and Accountability The Figure on page 7 shows longitudinal data for one Quality team leaders report to Butler and Granger each clinical area, heart attack care, over the time period of month to review data as a group. “Fallouts,” which are the quality improvement work. sometimes errors and other times omissions of docu- Flowers Hospital has not found that financial mentation, are discussed. It is not the goal to make rewards are a necessary part of their quality improve- fallouts punitive. When they occur due to an error, the ment strategy. Staff are committed to a culture of qual- manager discusses the error with the staff member, and ity improvement without monetary incentives. the staff member provides a written response about his Reinforcement is provided through personal, positive or her role and potential solutions to the problem. feedback and internal newsletters. Individual feedback Such interactions are not included in employees’ to physicians on their performance on these five condi- personnel files. tions has fallen by the wayside; the Quality Department used to post physician scores but, with everyone scoring so high, it decided there was no need to continue doing so. F lowers H ospital : N earing P erfection on C ore M easures 5 External recognition has come from the Another example of spreading the strategy is Alabama Hospital Association, the Alabama Quality the application to patient experience. Flowers, like Assurance Foundation (the Medicare Quality many U.S. hospitals, has recently begun to use the Improvement Organization), and the American HCAHPS survey to measures patients’ perspectives of Hospital Association. Granger chairs and Butler serves hospital care. But, unlike most hospitals, Flowers also on a statewide taskforce on quality improvement to assesses patients’ responses and aims to address any share Flowers’ experiences with colleagues at other deficiencies while they are still in the hospital, rather hospitals. Dozens of hospitals have toured Flowers to than waiting for HCAHPS results to come back weeks observe its successful work processes. CEO Keith or even months later. The Patient Care Services Granger has been recognized by the American Representative conducts daily surveys of a random Hospital Association for his leadership on quality and sample of inpatients, a total of 100 to 150 surveys a safety through grassroots work with the Alabama month. The questions mirror those in the HCAHPS Hospital Association. He also received the first Sherrill survey, covering the six domains of patient experience. Quality Award from the Alabama Quality Assurance If a problem is uncovered, the Patient Care Services Foundation in 2007. Representative addresses it immediately with the charge nurse. The data are also compiled longitudi- Lessons Learned nally and improvement efforts are developed to Flowers Hospital leaders believe the strategies address the problem systemically. HCAHPS results employed to improve performance on core measures provide the hospital with useful data for addressing can improve quality for many other conditions as well. system changes to benefit all patients. In the last several months, Flowers has begun compara- ble efforts to prevent several hospital-acquired patient For More Information conditions, including pressure ulcers, catheter-associ- For further information, contact Amy Butler, ated urinary tract infections, falls, and central line chief quality officer, amy_butler@chs.net or bloodstream infections. The early evidence is that the (334) 794-5000. techniques are transferable to these conditions as well. 6T he  C ommonwealth F und Table. Flowers’ Scores on 22 CMS Core Measures Compared with State and National Averages National Alabama Indicator Average Average Flowers Hospital Heart Failure Percent of heart failure patients given discharge instructions 69% 69% 93% of 263 patients Percent of heart failure patients given an evaluation of LVS function 87 85 100% of 305 patients Percent of heart failure patients given ACE inhibitor or ARB for LVS dysfunction 87 87 100% of 117 patients Percent of heart failure patients given smoking cessation advice/counseling 89 87 100% of 54 patients Pneumonia Percent of pneumonia patients given oxygenation assessment 99 99 100% of 197 patients Percent of pneumonia assessment patients assessed and given 78 75 98% of 152 patients pneumococcal vaccination Percent of pneumonia patients whose initial emergency room blood culture 90 90 99% of 152 patients was performed prior to the administration of the first hospital dose of antibiotics Percent of pneumonia patients given smoking cessation advice/ counseling 85 88 100% of 73 patients Percent of pneumonia patients given initial antibiotics within six hours after arrival 93 92 100% of 91 patients Percent of pneumonia patients given the most appropriate initial antibiotic(s) 87 84 99% of 109 patients Percent of pneumonia patients assessed and given influenza vaccination 75 72 98% of 54 patients Heart Attack Percent of heart attack patients given aspirin at arrival 94 87 100% of 143 patients Percent of heart attack patients given aspirin at discharge 91 90 100% of 236 Percent of heart attack patients given ACE inhibitor or ARB for LVS dysfunction 88 82 100% of 49 patients Percent of heart attack patients given smoking cessation advice/counseling 92 93 100% of 90 patients Percent of heart attack patients given beta blocker at discharge 92 86 100% of 244 patients Percent of heart attack patients given beta blocker at arrival 89 84 100% of 121 patients Percent of heart attack patients given fibrinolytic medication within 40 40 no patients met 30 minutes of arrival inclusion criteria Percent of heart attack patients given PCI within 90 minutes of arrival 67 69 94% of 33 patients Surgical Care Improvement/Surgical Infection Prevention Percent of surgery patients who received preventive antibiotics one hour 84 84 100% of 1127 patients before incision Percent of surgery patients who received the appropriate preventive 91 88 100% of 1132 patients antibiotics for their surgery Percent of surgery patients whose preventive antibiotics are stopped within 24 82 80 99% of 1073 patients hours after surgery Percent of surgery patients whose doctors ordered treatments to prevent blood 80 76 100% of 1264 patients clots (venous thromboembolism) for certain types of surgeries Percent of surgery patients who received treatment to prevent blood clots 77 73 100% of 1264 patients within 24 hours before or after selected surgeries Note: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blockers; LVS = left ventricular systolic; PCI = percutaneous coronary intervention. Source: www.hospitalcompare.hhs.gov. Accessed on 10/24/08. Data are from CY2007. F lowers H ospital : N earing P erfection on C ore M easures 7 Figure. Flowers Hospital Performance on Heart Attack Quality Measures, 2004–2007 Flowers Hospital Data: Acute Myocardial Infarction (AMI) National Top 10% National Average ASA at Arrival ASA at Discharge 105 105 100 100 95 95 Percentage Percentage 90 90 85 80 85 75 80 70 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 ACE Inhibitor/ARB at Discharge ACE Inhibitor/ARB at Discharge 105 105 100 100 95 95 90 90 85 85 Percentage Percentage 80 80 75 75 70 70 65 65 60 60 55 55 50 50 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 Beta Blocker at Discharge Beta Blocker at Arrival 105 105 100 100 95 Percentage Percentage 95 90 90 85 85 80 80 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 PCI within 120/90 Minutes 120 100 * 80 Percentage 60 40 *Effective 07/01/06 discharges - 20 PCI time decreased from 120 to 90 minutes 0 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 Note: ASA = acetylsalicylic acid; ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blockers; PCI = percutaneous coronary intervention. Source: Flowers Hospital, 2008. 8T he  C ommonwealth F und Appendix A. Selection Methodology Selection of high-performing hospitals in process-of-care measures for this series of case studies is based on data submitted by hospitals to the Centers for Medicare and Medicaid Services. We use 22 measures that are publicly available on the U.S. Department of Health and Human Services’ Hospital Compare Web site, Hospital Compare (www.hospitalcompare.hhs.gov). The 22 measures, developed by the Hospital Quality Alliance, relate to practices in four clinical areas: heart attack, heart failure, pneumonia, and surgical infections. Heart Attack Process-of-Care Measures Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Percent of Heart Attack Patients Given Aspirin at Arrival Percent of Heart Attack Patients Given Aspirin at Discharge Percent of Heart Attack Patients Given Beta Blocker at Arrival Percent of Heart Attack Patients Given Beta Blocker at Discharge Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes of Arrival Percent of Heart Attack Patients Given PCI Within 90 Minutes of Arrival Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling Heart Failure Process-of-Care Measures Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function Percent of Heart Failure Patients Given Discharge Instructions Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling Pneumonia Process-of-Care Measures Percent of Pneumonia Patients Assessed and Given Influenza Vaccination Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination Percent of Pneumonia Patients Given Initial Antibiotic(s) Within 4 Hours After Arrival Percent of Pneumonia Patients Given Oxygenation Assessment Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics Surgical Care Improvement/Surgical Infection Prevention Process-of-Care Measures Percent of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision Percent of Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery Percent of Surgery Patients Whose Preventative Antibiotic(s) Are Stopped Within 24 hours After Surgery The analysis uses all-payer data from the second quarter of 2006 through the first quarter of 2007. To be included, a hospital must have submitted data for all 22 measures (even if data submitted were based on zero cases), with a minimum of 30 cases for at least one measure in each of the four clinical areas. Approximately 80 percent of U.S. acute care hospitals submitted data on the 22 measures. Approximately 2,000 facilities—about half of acute care hospitals—were eligible for the analysis. No explicit weighting was incorporated, but higher-occurring cases give weight to that measure in the average. Since these are process measures (versus outcome measures), no risk adjustment was applied. Exclusion criteria and other specifications are available at http://www.qualitynet.org/dcs/ContentServer?cid=1141662756099&pagename= QnetPublic%2FPage%2FQnetTier2&c=Page). F lowers H ospital : N earing P erfection on C ore M easures 9 Appendix B. Physician-Designed Progress Note for AMI and Appendix B. Physician-Designed Progress Note for AMI and Heart Failure Patients Heart Failure Patients AMI / CHF Criteria Physician Record  Not Applicable (No AMI or LVEF > 40%) The first four indicators apply to AMI only: Patient  ASA Ordered Within First 24 Hours Identificatio  EXCLUSIONS / CONTRAINDICATIONS: n  ASA allergy/intolerance  Active bleeding on arrival or within 24 hrs  Coumadin as Pre- arrival medication  Other reason as documented by physician: ______________________________________________________  Beta Blocker ordered within first 24 hours  EXCLUSIONS / CONTRAINDICATIONS:  Beta Blocker allergy or intolerance  Heart rate less than 60 on arrival or within 24 hrs  Heart failure on arrival or within 24 hrs  2nd or 3rd degree heart block on arrival or within 24 hrs and does not have a Pacemaker  COPD, Asthma  Shock on arrival or within 24 hrs  SBP < 90 mmHG on arrival or within 24 hrs  Other reason documented by physician: ________________________________________________________  ASA Ordered at Discharge  EXCLUSIONS / CONTRAINDICATIONS:  ASA allergy/intolerance  Active bleeding on arrival or within 24 hrs  Coumadin as Pre- arrival medication  Other reason as documented by physician: ______________________________________________________  Beta Blocker ordered at discharge  EXCLUSIONS / CONTRAINDICATIONS:  Beta Blocker allergy or intolerance  Heart rate less than 60 on day of discharge or day prior to discharge while not on a Beta Blocker  COPD, Asthma  2nd or 3rd degree heart block on arrival or during hospital stay and does not have a Pacemaker  SBP < 90 mmHG on day of discharge or day prior to discharge while not on a Beta Blocker  Other reason as documented by physician: ______________________________________________________ The following two indicators apply to AMI & CHF: 13 10T he  C ommonwealth F und  LV Systolic function assessed / previously assessed / known to be:  Normal  Mildly Impaired (40% – 50%)  Moderately Impaired (30% – 40%)  Severely Impaired (< 30%)  Ace Inhibitor / ARB ordered at discharge (Indicated for EF < 40%)  EXCLUSIONS CONTRAINDICATIONS:  Allergy/Intolerance to ACEI & ARB  Aortic Stenosis – Moderate or Severe  SBP < than 100  Other reason documented by physician: _________________________________________________________ Additional Indicators:  Smoking Cessation Counseling  CHF Written Discharge Instructions Ordered CHF CLASSIFICATION (Select ONE from EACH Column) CHECK ONE OF THE FOLLOWING: CHECK ONE OF THE FOLLOWING:  Acute Heart Failure  Systolic Heart Failure  Chronic Heart Failure  Diastolic Heart Failure  Acute on Chronic Heart Failure  Systolic and Diastolic Heart Failure ____________________________ _____________ Physician Signature Date 14 F lowers H ospital : N earing P erfection on C ore M easures 11 A bout the A uthor Jennifer Edwards, Dr.P.H., M.H.S., is a principal with Health Management Associates’ New York City office. Jennifer has worked for 20 years as a researcher and policy analyst at the state and national levels to design, evaluate, and improve health care coverage programs for vulnerable populations. She worked for four years as senior program officer at The Commonwealth Fund, directing the State Innovations program and the Health in New York City program. She has also worked in quality and patient safety at Memorial Sloan-Kettering Cancer Center, where she was instrumental in launching the hospital’s Patient Safety program. Jennifer earned a Doctor of Public Health degree at the University of Michigan and a Master of Health Science degree at Johns Hopkins University. A cknowledgments We wish to thank Amy Butler for generously sharing her time, knowledge, and materials with us. Editorial support was provided by Martha Hostetter. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.