Case Study High-Performing Health Care Organization • March 2009 April 2009 Oklahoma Heart Hospital: Clinician Leaders Establish Culture of Quality S haron S ilow -C arroll , M.B.A., M.S.W. H ealth M anagement A ssociates Vital Signs Location: Oklahoma City, Okla. The mission of The Commonwealth Type: Small, physician-owned, for-profit hospital specializing in cardiac care. Fund is to promote a high performance health care system. The Fund carries Beds: 78 out this mandate by supporting Distinction: Top 1 percentile (with a score of 99.1% compliance) in a composite of 24 process-of- independent research on health care care quality measures, among more than 2,000 acute-care hospitals—about half of the acute-care issues and making grants to improve hospitals in the U.S.—eligible for the analysis. health care practice and policy. Support for this research was provided by Timeframe: January through December 2007. See Appendix A for full methodology. The Commonwealth Fund. The views This case study describes the strategies and factors that appear to contribute to high adherence to presented here are those of the authors process-of-care, “core” measures at Oklahoma Heart Hospital. It is based on information obtained and not necessarily those of The from interviews with key hospital personnel, publicly available information, and materials provided by Commonwealth Fund or its directors, the hospital during October 2008 through January 2009.1 officers, or staff.      Summary For more information about this study, Since its inception in 2002, Oklahoma Heart Hospital (OK Heart) has consis- please contact: tently demonstrated high adherence to process-of-care or “core” measures and Sharon Silow-Carroll, M.B.A., M.S.W. high patient satisfaction.2 Reinforced by positive financial performance, OK Health Management Associates E-mail ssilowcarroll@ Heart leaders are dedicated to pursuing and maintaining optimal quality and healthmanagement.com patient service. Key strategies behind their excellent scores in core measure stan- dards include: • Physician leaders’ commitment to quality; • Physician offices housed within the hospital, providing greater access To download this publication and to nurses and patients; learn about others as they become available, visit us online at • Flat organizational structure that allows quick implementation of www.commonwealthfund.org and operational changes; register to receive Fund e-Alerts. Commonwealth Fund pub. 1251 • Highly experienced nurses and high nurse-to-patient ratios; Vol. 14 2T he  C ommonwealth F und • Standardization of care processes through emergency room and admits more than 1,000 patients computerized “care sets”; annually from this service. OK Heart also has four open-heart/peripheral vascular surgical suites and five • Electronic tools (e.g., electronic medical cardiac and peripheral vascular catheterization labs. records, computerized physician order entry) that provide immediate access to patients’ Strategies for Success medical information and feedback about Based on conversations with OK Heart leaders, the appropriate orders, thereby reducing errors; hospital’s achievements in core measure scores and • Continuous examination of existing practices other quality measures can be attributed to the follow- and introduction of new practices; and ing factors and strategies. • An “e-Bucket” tool for communicating staff concerns and addressing them quickly. Culture of Quality and Flat Organizational Structure Oklahoma Heart was established by a group of about Organization 40 physicians who wanted to provide quality care and Oklahoma Heart Hospital, which opened in 2002 in were frustrated with the bureaucracy in conventional Oklahoma City, is the state’s first dedicated heart hos- health care settings. Their commitment to quality was pital. It is a physician-owned cooperative arrangement the foundation of OK Heart’s culture. “Quality and between the Oklahoma Cardiovascular Associates, the patient service are the reason for OK Heart’s exis- state’s largest group of cardiologists, and the Sisters of tence,” said Peggy Tipton, chief operating officer Mercy Health System. OK Heart contains 78 patient (COO) and chief nursing officer. beds and has an average daily census of about 75 Leaders attribute the ongoing quality focus to patients. Average length of stay for patients is 3.25 clinician and caregiver leadership at the executive and days. Patient mix is 63 percent Medicare, 2 percent board levels. The CEO is a practicing cardiologist, the Medicaid, 30 percent commercial insurance, and 4 COO is a nurse, and the board is composed largely of percent uninsured, with patients from all 77 Oklahoma physicians. “Every decision we make is based on: counties. OK Heart describes itself as the first all- ‘how will it affect the patient?’ Financial and produc- digital, or paperless, hospital in the United States. tivity considerations are secondary,” said Tipton. In addition to its success with core measure So far, the focus on quality has resulted in quality scores, OK Heart has achieved optimal patient favorable financial performance. “We spend more money satisfaction. It was ranked in the top 1 percent nation- on what helps patient care and less on secondary items ally in 2006, 2007, and 2008, according to Press such as other lines of business, new buildings, and Ganey Associates, an organization that measures administrators,” said CEO John Harvey, M.D. patient satisfaction. Some critics argue that small, spe- Limiting the size of the hospital and scope of cialty hospitals score better on quality measures services allows for a relatively flat organizational because they tend to have healthier patients and sim- structure, without a need for a large committee struc- pler cases. However, OK Heart administrators state ture or bureaucracy. This enables the hospital to imple- that their patients tend to have complex conditions and ment operational changes based on new clinical evi- are sicker than average, with a case-mix index of 2.19 dence or internal decisions quickly and efficiently. for fiscal year 2009 (higher figures signify more com- Finally, physicians’ offices are housed in the plexity), compared with a nationwide average of 1.37.3 hospital, which enhances nurse–physician relationships OK Heart Hospital performs 12,000 interventions and physicians’ accessibility to patients. and 3,000 surgeries annually. It offers a full-service O klahoma H eart H ospital : C linician L eaders E stablish C ulture of Q uality 3 Optimal Nurse Experience and Ratios National Database of Nursing Quality Indicators sur- The quality and quantity of nursing staff are key con- vey, and has a 98 percent nurse retention rate, reducing tributors to the high-quality care at OK Heart. The the need for expensive recruitment and training. hospital hires slowly and carefully, making sure it acquires compassionate individuals who can make a Standardization through Care Sets contribution to quality, rather than using productivity and High Volume or cost ratios in staffing decisions. The average nurse OK Heart has developed and uses approximately 124 at OK Heart has nearly 10 years of experience. care sets, based on disease or procedure. They are Despite nursing shortages, OK Heart maintains written by OK Heart physicians with the collaboration optimum nurse-to-patient ratios of one nurse per of nurses, often building on best practices developed patient in critical care units, one nurse per three by national experts. If a patient with chest pain is patients in step-down care, and one nurse per four admitted through the emergency room, for example, patients in medical–surgical units. This ratio amounts the physician on duty will request a chest pain care to fewer patients per nurse than is the norm in most set. The care set may be modified, if the situation war- hospitals.4 “These staffing levels allow nurses to really rants it, but the default is evidence-based protocol. The concentrate on high-quality patient care,” said Tipton. care sets provide checklists for clinicians to standard- The staffing levels also illustrate the administration’s ize care, reduce errors, and ensure compliance with claim that finances do not come first; quality is the evidence-based procedures. See Figures 1 and 2 for top priority. OK Heart’s heart failure and acute coronary syndrome The staffing levels, along with nurse education care sets. and involvement in decision-making, have benefited Though small in bed size, OK Heart is a large- the hospital financially. OK Heart ranks in the 90th volume hospital, performing about 1,200 open-heart percentile in nursing satisfaction, according to a 2008 surgeries per year and about 500 cardiac catheterizations Figure 1. Heart Failure Care Set 4T he  C ommonwealth F und per month. This combination of standardization and Electronic measurement also allows for continual high volume has contributed immensely to high-quality feedback, with rapid assessment of compliance with care, according to Cindy Miller, multi-department director. core measures. This, in turn, allows the staff to correct situations and implement proper procedures quickly. Technology Allows for Quick Feedback, The core measures are reported in all staff meetings, Assessment, and Correction reinforcing staff success at complying with the stan- The founders of OK Heart invested in information dards. “Electronic medical records transform the technology (IT) systems to reduce errors, improve way OK Heart clinicians practice medicine,” said communication, and maximize evidence-based prac- Miller. tice. As an entirely paperless organization, OK Heart The electronic system does require mainte- has bedside computers in every room so nurses and nance. An IT team meets regularly with the clinical physicians can access test results and care sets while staff to maintain and revise the electronic medical they are with patients. The systems include and inte- record and support systems. The rapidly changing grate care sets, computerized physician order entry, technology and evidence-based practices require and electronic medical records. For example, if a users to be nimble and to adapt to changes quickly. physician writes an order, the nurse’s task list is imme- Downtimes, primarily for system updates, are sched- diately updated, and the pharmacist verifies the order uled, with performance during the downtimes and sends the medication to the floor within about reviewed to ensure safety and patient care. 10 minutes. Figure 2. Acute Coronary Syndrome Care Set O klahoma H eart H ospital : C linician L eaders E stablish C ulture of Q uality 5 Continually Examining and Introducing They established protocols to treat both surgical and New Practices medical patients with elevated blood sugar. Patients The minimal bureaucracy, ongoing feedback through with blood sugar levels greater than 200 or less than IT, and overall culture of quality allow OK Heart to 50 are seen in consult by the nurse specialist. The hos- respond to problems and new clinical evidence and pital continues to educate patients and staff as evi- quickly and efficiently incorporate new practices. dence-based practice in controlling glucose evolves. Problem identification and implementation of best These efforts are reflected in a core measure, which is practices are illustrated in the following examples. reported to the Centers for Medicare and Medicaid Services (CMS). At OK Heart, the percent of all heart Depression Screening and Treatment surgery patients with blood sugar (blood glucose) The medical literature documents a clear connection under good control in the days right after surgery is 96 between depression and heart disease. Consequently, percent, compared with 90 percent in Oklahoma and OK Heart senior staff examined current practices and 90 percent nationwide.5 recognized the need to improve patient care. The hos- pital hired a full-time psychologist to help identify, Induced Hypothermia (“Big Chill”) for treat, and refer patients, when necessary. A depression Cardiac Arrest Patients screening tool was added to the initial nursing assess- An article was presented to the nursing leadership ment. Patients requiring help are referred to the about the success of induced hypothermia—reducing psychologist for assessment and follow-up. Medical patient core temperature to 32ºC to 34ºC for 12 to 24 and nursing staff may also make referrals if patients hours—for cardiac arrest patients. Clinical trials of exhibit signs and symptoms of depression after the induced hypothermia indicate this treatment may initial assessment. In 2007, the psychologist received improve survival and neurological recovery in patients referrals in over 25 percent of the patient population. who have cardiac arrest under certain conditions.6 The psychologist also educates medical and nursing Within two weeks of introducing the concept, OK staff in prevention, assessment, treatment and follow- Heart used the practice on a patient. Soon after, OK up of patients. Miller believes that these efforts are Heart was one of the first hospitals in the nation to ini- reflected in their high patient satisfaction scores and tiate an induced hypothermia protocol for patients low mortality rates. meeting certain conditions. Historically, patients who have out-of-hospital Addressing Diabetes cardiac arrest have had high mortality and morbidity Noticing that many patients were diabetic or had ele- rates; more than 90 percent of these patients die before vated blood sugars during hospitalization, OK Heart reaching the hospital, and severe neurological impair- conducted a systematic examination of blood sugar ment often develops in those who do survive after levels as part of an effort to improve outcomes for sur- resuscitation. 7 An examination of OK Heart’s early gical and medical patients. In 2006, staff performed a experience with the hypothermia protocol found sur- hemoglobin A1c test on every admission and found vival and neurologic recovery comparing favorably that over 15 percent of the patient population had with clinical trial outcomes.8 uncontrolled blood sugar and over 35 percent of Since 2004, OK Heart has used its “Big Chill” patients experienced elevated levels during hospitaliza- protocol on over 150 patients, with a survival rate of tion. Half of the latter group had undiagnosed diabetes. 38 percent. Over one-half of the survivors have returned Administration began a mandatory education program, to their pre-arrest quality of life. OK Heart is the only hiring a nurse specialist and diabetes dieticians to edu- hospital in Oklahoma that offers induced hypothermia cate staff, patients, and families regarding the impor- protocols for patients experiencing “un-witnessed” car- tance of blood sugar control during hospitalization. diac arrest (e.g., situations involving a delay of at least 10 minutes before heart function is restored). 6T he  C ommonwealth F und Strategies to Reduce Surgical Site Infections Results The rate of surgical site infections for implantable OK Heart has excelled in creating quality outcomes devices should be less than 1 percent. In 2006, OK and generating patient satisfaction since it opened in Heart experienced rates above this benchmark and 2002. High scores have been connected to positive instituted an epidemiological investigation that found financial performance: the hospital received the maxi- the increased incidence of infection was physician- mum payment from CMS for performance in evidence- specific. Further investigation found problems with long based core measures and was recently selected as a cases, inappropriate administration of prophylactic cardiac referral center for Medicare’s Acute Care antibiotics, issues with preoperative skin preparation, Episode project.9 These experiences have reinforced and basic surgical asepsis. the hospital’s commitment to quality. In response, the hospital implemented a series Based on data reported to CMS, OK Heart of prevention strategies including: educating staff, received the Total Benchmark Solution Top 100 observing cases by infection control personnel, super- Quality Award for Best Acute Care Hospitals in vising physicians, and monitoring surgical asepsis by 2006.10 It has reached 100 percent compliance on the operating room staff. Rates of infection returned to majority of core measure indicators, far surpassing benchmark levels in less than six months, and inci- both state and national averages (Figure 3). dence of surgical site infection now remains at an Despite excellent scores and recognition, OK acceptable level. Heart has, over the years, identified areas in need of improvement. These have included prevention of com- Prevention Bundles to Reduce Ventilator-Associated plications with implantable devices and reduction in Pneumonia ventilator-associated pneumonias. Efforts to address In an effort to reduce rates of ventilator-associated these areas, described in this case study, have led to pneumonia, OK Heart implemented “prevention bun- changes in practices that have largely been successful. dles” for ventilated patients that include elevating the OK Heart continues to work on ensuring that patients head of the bed, extubation, and mouth care. The bun- are comfortable with home care and after-care, by dles were incorporated into nurses’ practices, with carefully monitoring the discharge processes and infection rates closely monitored by infection control readmission rates. personnel. Infection rates have not changed since the bundles were implemented, though they continue to be Lessons Learned at acceptable levels—lower than 25th percentile of Though OK Heart is small and specializes in cardiac National Safety Health Network rates. Still, the hospital care, CEO John Harvey thinks the strategies that have is continuing efforts toward further infection reduction. contributed to its success are replicable in other hospi- tal settings. “The key is to put practitioners back in the Addressing Staff Concerns role of decision-making and to put patients back on Staff members are encouraged to communicate con- top as a priority,” he said. cerns, including those involving core measures, Another lesson emerging from OK Heart’s expe- through an “e-Bucket,” a designated e-mail address. rience, according to COO Peggy Tipton, is that “improv- The quality improvement staff review items in the ing quality is a journey that never ends.” It requires bucket each day and address problems within 24 persistence, commitment, and a clear message from hours. This tool is particularly helpful in enabling the top of the organization. “The quest for quality must nurses to report concerns about quality related to patient permeate what we do and communicate,” said Miller. care, management, or safety without fear of retribution. OK Heart leaders admit there are challenges. Changing physician and nurse behavior requires O klahoma H eart H ospital : C linician L eaders E stablish C ulture of Q uality 7 Figure 3. Oklahoma Heart Hospital Scores on 24 CMS Core Measures Compared with State and National Averages, April 2007–March 2008 Indicator National Oklahoma Oklahoma Heart Average Average Hospital Heart Failure Percent of heart failure patients given discharge instructions 71% 60% 100% of 295 patients Percent of heart failure patients given an evaluation of LVS function 87% 75% 100% of 315 patients Percent of heart failure patients given ACE inhibitor or ARB for LVS dysfunction 88% 86% 100% of 160 patients Percent of heart failure patients given smoking cessation advice/counseling 90% 79% 100% of 45 patients Pneumonia Percent of pneumonia patients given oxygenation assessment 99% 99% 100% of 20 patients* Percent of pneumonia assessment patients assessed and given pneumococcal 80% 78% 100% of 37 patients vaccination Percent of pneumonia patients whose initial emergency room blood culture was 90% 90% 92% of 13 patients* performed prior to the administration of the first hospital dose of antibiotics Percent of pneumonia patients given smoking cessation advice/counseling 87% 80% 100% of 19 patients* Percent of pneumonia patients given initial antibiotics within six hours after arrival 93% 93% 100% of 14 patients* Percent of pneumonia patients given the most appropriate initial antibiotic(s) 87% 84% 91% of 11 patients* Percent of pneumonia patients assessed and given influenza vaccination 79% 78% 100% of 32 patients* Heart Attack Percent of heart attack patients given aspirin at arrival 94% 84% 100% of 82 patients Percent of heart attack patients given aspirin at discharge 91% 87% 100% of 288 patients Percent of heart attack patients given ACE inhibitor or ARB for LVS dysfunction 89% 88% 100% of 35 patients* Percent of heart attack patients given smoking cessation advice/counseling 93% 87% 100% of 134 patients Percent of heart attack patients given beta blocker at discharge 92% 81% 100% of 270 patients Percent of heart attack patients given fibrinolytic medication within 30 minutes of arrival 41% 36% 0 patients* Percent of heart attack patients given PCI within 90 minutes of arrival 70% 69% 83% of 18 patients* Surgical Care Improvement Percent of surgery patients who were given an antibiotic at the right time (within one 85% 80% 100% of 256 patients hour before surgery) to help prevent infection Percent of surgery patients who were given the right kind of antibiotic to help prevent 92% 86% 100% of 265 patients infection Percent of surgery patients whose preventative antibiotics were stopped at the right 83% 86% 98% of 178 patients time (within 24 hours after surgery) Percent of all heart surgery patients whose blood glucose is kept under good control in 86% 90% 96% of 49 patients the days right after surgery Percent of surgery patients needing hair removal from the surgical area before surgery, who had hair removed using a safe method (electric clippers or hair removal cream, 95% 93% 100% of 96 patients not razor) Percent of surgery patients whose doctors ordered treatments to prevent blood clots 82% 74% 50% of 2 patients* after certain types of surgeries Percent of surgery patients who got treatment at the right time (within 24 hours before 79% 72% 50% of 2 patients* or after their surgery) to help prevent blood clots after certain types of surgery Note: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blockers; LVS = left ventricular systolic; PCI = percutaneous coronary intervention. *The number of cases is too small (<25) to reliably tell how well a hospital is performing. Note: The majority of OK Heart’s community-acquired pneumonia cases present to their Emergency Department and are admitted or referred to another facility depending on bed availability. Source: www.hospitalcompare.hhs.gov. Accessed Fall 2008. Data are from CY2007. 8T he  C ommonwealth F und education and discipline, and such efforts by adminis- N otes tration and superiors are not always welcome. It helps to examine data at the individual physician and nurse 1 This study was based on publicly available infor- mation and self-reported data provided by the case levels and then let providers know when their behav- study institution(s). The aim of Fund-sponsored case iors or outcomes fall outside expectations. It is also studies of this type is to identify institutions that important for the physician governing board to inter- have achieved results indicating high performance vene to encourage physicians to change behavior. in a particular area, have undertaken innovations Medical staff members know that their individual designed to reach higher performance, or exemplify performance on quality measures affects peer review attributes that can foster high performance. The and recredentialing. studies are intended to enable other institutions to draw lessons from the studied organizations’ experi- Providing feedback quickly and continually is ences in ways that may aid their own efforts to critical. OK Heart medical staff view their own com- become high performers. The Commonwealth Fund pliance data quarterly, but are informed of variances is not an accreditor of health care organizations from standards when they occur. It is also helpful to or systems, and the inclusion of an institution in the inform physicians of how they compare with others. Fund’s case studies series is not an endorsement by the “Physicians are competitive; they want to take good Fund for receipt of health care from the institution. care of their patients and be the best in among their 2 The core measures are a set of care processes peers,” said Miller. developed by The Joint Commission, the predomi- nant accrediting body for health care institutions, to For More Information improve health outcomes. Also called “process-of- For further information, contact Cindy Miller, care” measures, hospitals’ adherence to the care pro- M.S.N., multi-department director, email: cesses is reported to the Centers for Medicare and Medicaid Services and made public on the Hospital cmiller@okheart.com. Compare Web site (http://www.hospitalcompare. hhs.gov). High performance on these measures is the main criteria for selection for this publication series. 3 A hospital’s case mix index (CMI) represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. Average CMI among 3,619 hospitals is 1.37 for fiscal year 2009 (Centers for Medicare and Medicaid Services, FY 2009 CMS Final Rule Case Mix Index, http://www. cms.hhs.gov/AcuteInpatientPPS/FFD/itemdetail.asp ?filterType=none&filterByDID=0&sortByDID=2&s ortOrder=descending&itemID=CMS1214021&intN umPerPage=10). O klahoma H eart H ospital : C linician L eaders E stablish C ulture of Q uality 9 4 Recommendations for minimum nurse-to-patient ratios vary considerably, from one nurse per 10 patients (recommended by hospital associations), to one nurse per three patients (recommended by nurses’ associations). California, the only state to mandate minimum nurse-to-patient ratios, has minimum ratios of 1:5 in medical/surgical units, 1:2 in critical care units and ICUs, and 1:3 in step-down units. For more information see: Nurse-to-Patient Ratios: Research and Reality, NEPPC, Conference Report Series No. 05–1, July 2005. http://www. bos.frb.org/economic/neppc/conreports/2005/ conreport051.pdf. 5 Based on data reported for discharges January 2008 through March 2008. Hospital Compare Web site: www.hospitalcompare.hhs.gov. 6 For more information on hypothermia after cardiac arrest, see: Hypothermia After Cardiac Arrest Study Group, “Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest,” New England Journal of Medicine, Feb. 21, 2002 346(8):549–56; S. A. Bernard, T. W. Gray, M. D. Buist et al., “Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypo- thermia,” New England Journal of Medicine, Feb. 21, 2002 346(8):557–63; and B. D. Scott, T. Hogue, M. S. Fixley et al., “Induced Hypothermia Follow- ing Out-of-Hospital Cardiac Arrest; Initial Experi- ence in a Community Hospital,” Clinical Cardiol- ogy, Dec. 2006 29(12):525–29. 7 See: T. Kozik, “Induced Hypothermia for Patients with Cardiac Arrest: Role of a Clinical Nurse Spe- cialist,” Critical Care Nurse, Oct. 2007 27(5):36–43. 8 Scott, Hogue, Fixley et al., “Induced Hypothermia,” 2006. 9 On Jan. 1, 2009, the Centers for Medicare and Medicaid Services launched a three-year acute care episode demonstration project that involves bundling Medicare payments to selected hospitals and physicians into a single payment. The project is designed to test the use of a single payment for an “episode of care,” defined as both hospital and physician services furnished to a patient during an inpatient stay. 10 For more information see: http://www.totalbench- marksolution.com/index.php?id=86 . 10T 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 24 measures that are publicly available on the U.S. Department of Health and Human Services’ Hospital Compare Web site (www.hospitalcompare.hhs.gov). The 24 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 1. Percent of heart attack patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) 2. Percent of heart attack patients given aspirin at arrival 3. Percent of heart attack patients given aspirin at discharge 4. Percent of heart attack patients given beta blocker at arrival 5. Percent of heart attack patients given beta blocker at discharge 6. Percent of heart attack patients given fibrinolytic medication within 30 minutes of arrival 7. Percent of heart attack patients given PCI within 90 minutes of arrival 8. Percent of heart attack patients given smoking cessation advice/counseling Heart Failure Process-of-Care Measures 9. Percent of heart failure patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) 10. Percent of heart failure patients given an evaluation of left ventricular systolic (LVS) function 11. Percent of heart failure patients given discharge instructions 12. Percent of heart failure patients given smoking cessation advice/counseling Pneumonia Process-of-Care Measures 13. Percent of pneumonia patients assessed and given influenza vaccination 14. Percent of pneumonia patients assessed and given pneumococcal vaccination 15. Percent of pneumonia patients given initial antibiotic(s) within 4 hours after arrival 16. Percent of pneumonia patients given oxygenation assessment 17. Percent of pneumonia patients given smoking cessation advice/counseling 18. Percent of pneumonia patients given the most appropriate initial antibiotic(s) 19. 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 Process-of-Care Measures 20. Percent of surgery patients who received preventative antibiotic(s) one hour before incision 21. Percent of surgery patients who received the appropriate preventative antibiotic(s) for their surgery 22. Percent of surgery patients whose preventative antibiotic(s) are stopped within 24 hours after surgery 23. Percent of surgery patients whose doctors ordered treatments to prevent blood clots (venous thromboembolism) for certain types of surgeries 24. Percent of surgery patients who received treatment to prevent blood clots within 24 hours before or after selected surgeries O klahoma H eart H ospital : C linician L eaders E stablish C ulture of Q uality 11 The analysis uses all-payer data from all four quarters in 2007. To be included, a hospital must have submitted data for all 24 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 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 aver- age. 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&pagena me=QnetPublic%2FPage%2FQnetTier2&c=Page). While high score on a composite of process-of-care measures was the primary criteria for selection in this series, the hospitals also had to meet the following criteria: ranked within the top half of hospitals in the U.S. in the percentage of patients who gave a rating of 9 or 10 out of 10 when asked how they rate the hospital overall (measured by Hospital Consumer Assessment of Healthcare Providers and Systems, HCAHPS), full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity. A bout the A uthor Sharon Silow-Carroll, M.B.A., M.S.W., is a health policy analyst with nearly 20 years of experience in health care research. She has specialized in health system reforms at the local, state, and national levels; strategies by hospitals to improve quality and patient-centered care; public–private partnerships to improve the performance of the health care system; and efforts to meet the needs of underserved populations. Prior to joining Health Management Associates as a principal, she was senior vice president at the Economic and Social Research Institute, where she directed and conducted research studies and authored numerous reports and articles on a range of health care issues. A cknowledgments We wish to thank John Harvey, M.D., chief executive officer; Cindy Miller, M.S.N., multi-department director; and Peggy Tipton, R.N., B.S.N., chief operating officer and chief nursing officer, for generously sharing their 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.