Case Study High-Performing Health Care Organization • March 2009 June 2009 NorthShore University Health System: Achieving Rapid Improvement on Core Measures J ennifer N. 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: Evanston, Illinois, a northern suburb of Chicago out this mandate by supporting Type: Teaching, not-for-profit community hospital system independent research on health care Beds: 650 beds across three hospitals issues and making grants to improve health care practice and policy. Support Distinction: Top 1 percent of hospitals in composite of 24 process-of-care quality measures among for this research was provided by roughly 2,000 hospitals (about half of U.S. acute-care hospitals) eligible for the analysis. The Commonwealth Fund. The views Timeframe: Calendar year 2007. To be included, hospitals must have submitted data to the Centers presented here are those of the authors for Medicare and Medicaid Services (CMS) for all 24 measures, with a minimum of 30 cases for at and not necessarily those of The least one measure in each of four clinical areas. See Appendix A for full methodology. Commonwealth Fund or its directors, officers, or staff.      Summary In 2007, NorthShore University Health System achieved 97 percent compliance For more information about this study, please contact: with Centers for Medicare and Medicaid Services (CMS) process-of-care mea- Jennifer N. Edwards, Dr.P.H. sures, a 12-point increase from just one year before.2 The measures, developed by Health Management Associates the Hospital Quality Alliance, relate to achievement of recommended treatment in jedwards@healthmanagement.com four clinical areas: heart attack, heart failure, pneumonia, and surgical care. NorthShore’s rapid improvement was triggered by a conversation between the president and chief executive officer of the health system, Mark Neaman, and Liz Behrens, R.N., M.S.N., vice president of quality improvement, during which Behrens suggested that NorthShore make CMS core measures a priority. With To download this publication and high-level endorsement, NorthShore pursued the following improvement strategies: learn about others as they become available, visit us online at www.commonwealthfund.org and • a system-wide staff education initiative led by the quality department, register to receive Fund e-Alerts. including the essential engagement of medical staff, pharmacists, Commonwealth Fund pub. 1287 and nurses; Vol. 23 2T he  C ommonwealth F und • promoting physician buy-in by encouraging System-Wide Staff Education them to contact CMS with questions about the NorthShore’s transformation began with the introduc- care standards; tion of the CMS process-of-care measures to staff • use of an electronic health record (EHR) sys- across the three hospitals. At that point, Behrens and tem as a tool in education, care management, her team learned that many physicians were committed and performance tracking; and to their usual practices, particularly the use of certain drugs. Some were difficult to engage because they • use of real-time data for concurrent review of felt certain measures, such as prevention of deep-vein patient care, made possible by exporting data thrombosis among orthopedic patients, were not rel- from the EHR. evant to their patients. NorthShore has sustained its performance To promote acceptance of the quality measures, improvements, scoring 96 percent or higher on 23 of NorthShore formed teams of physicians, nurses, and the 25 core measures through June 2008. pharmacists to review, discuss, and adapt the CMS care standards. Teams examined existing care practices at Organization NorthShore and found wide variations. In the end, they Evanston Northwestern Healthcare was formed in were convinced by the evidence base demonstrating 2000 through the merger of three Chicago-area hospi- the effectiveness of the recommended processes of care. tals: Evanston Hospital, founded in 1891, Glenbrook The teams developed care processes consistent with the Hospital, established in 1977, and Highland Park CMS indicators, specifying cases in which exceptions Hospital. A fourth institution, Skokie Hospital, joined should be allowed. Pharmacists played an important in January 2009. The health system also includes a role, ultimately becoming powerful advocates for the research institute, a home health care provider, and pharmaceutical standards, such as the correct use, tim- a network of physicians’ offices. It is a training site ing, and discontinuation of antibiotics. Care processes for the University of Chicago’s Pritzker School of were codified in order sets in the health system’s Medicine. In November 2008, the system changed its EHRs. The high level of clinician buy-in has carried name to NorthShore University Health System. through to subsequent quality improvement efforts. All NorthShore Nurses were trained in the new Strategies for Success care processes and the stringent compliance standards. Improvement efforts at NorthShore have been wide- Their involvement on the review teams led to changes spread and involved doctors, nurses, pharmacists, in nursing processes, including daily rounds (discussed information systems specialists, discharge planners, below). quality improvement staff, and executives. The most important strategy, according to Behrens, was the move Connecting Physicians to CMS from retrospective data review for patients who had While the initial work by clinical teams was critical, already been discharged to concurrent monitoring of engaging all of NorthShore’s physicians continued patients, which allows for improvements in care while to be a challenge. Behrens noted in particular the dif- there is still time. Concurrent monitoring enables phy- ficulty of making clear that care could not be con- sicians to identify instances when their care choices sidered compliant with CMS measures unless it was do not meet standards, giving them a chance to change delivered—and documented—according to standards. their orders. By raising their awareness of gaps in care, Physicians who questioned the requirements were doctors and quality staff were able to design better and encouraged to submit their questions to QualityNet, a more reliable processes for achieving quality goals. quality improvement Web site created by CMS. CMS representatives responded directly to physicians. When N orth S hore U niversity H ealth S ystem 3 the message was delivered by a health care payer, data and enables them to alert clinicians about gaps rather than the hospital’s quality department, it held in quality while patients are still in the hospital. more weight. Behrens believed that engaging doctors Introduction of this reporting system would not have in the discussions about the appropriateness of docu- been possible without an EHR. To serve additional menting care and exceptions has transformed their role needs, the daily reports are aggregated for review at in quality improvement. weekly meetings or by managers. With time, the medical staff began to embrace A daily tracking report is automatically gener- the quality goals and work out some of the challenges ated from the data warehouse for each unit, showing in meeting the new care standards. For example, car- which patients are up-to-date on core measures and diologists and emergency department physicians spent which have needs to be addressed (highlighted in yel- time reviewing cases to reach agreement on which low) (Exhibit 1). The tracking report is used in an patients should be considered eligible for the heart auditing process created by the nursing staff. For each attack and heart failure protocols. They reviewed patient with a condition related to the core measures, all heart attack patients with ST-segment eleva- nursing unit leaders review the care processes with the tions (known as STEMI patients) within 24 hours of floor staff during daily 15-minute rounds. The report arrival, to determine how well care processes worked makes it easy to see where nursing actions are needed, and define new protocols where needed. Clear inclu- helping to ensure that medications are provided on a sion and exclusion criteria reduced the likelihood schedule and patients receive appropriate education. that a patient eligible for a particular protocol would This system has led to interventions prior to patient be missed. Plus, working through the requirements discharge, as well as proper documentation of reasons improved physicians’ documentation of care. As a for non-compliance with the care standards. Nurses result of this type of improvement process, Behrens also use the tracking reports to review patterns of says that physicians and other stakeholders, rather than missed care and redesign systems when needed. the quality department, “own their outcomes.” The pharmacy department also performs daily monitoring using EHRs. Pharmacists check on new- Real-Time Data: The End of “Hinting core-measure patients, verifying that the appropriate and Hoping” medications have been ordered. Physicians and Before 2006, NorthShore’s quality department used pharmacists confer when opportunities to change data in what it described as a “hinting and hoping” medication are identified. In addition, pharmacists style. In an attempt to inspire improvement, the depart- review the end time of a procedure to ensure that ment posted data illustrating deficiencies in care or antibiotics are scheduled to be completed within 24 documentation. The data were four to six months old. hours after surgery. When quality staff asked physicians why a patient’s care was outside the norm, they often could not Electronic Health Record Tools remember the circumstances that may have justified In addition to facilitating concurrent reviews of patient the exception to care standards—and the chance to care, NorthShore’s EHR has given staff tools to sustain document it was long gone. Such efforts did not lead to success, according to Maureen Kharasch, director of changes in clinical behavior. quality and patient safety. For example, the system’s In 2006, the quality department instituted a new Vaccine Navigator helps nurses work through the system of data reporting to help track adherence to core inclusion/exclusion criteria to determine if a patient is measures and support daily rounding. Each night, data eligible to receive the pneumonia vaccine (Exhibit 2). from the EHRs are automatically exported to the data If criteria are met, a nurse follows a link provided to warehouse for aggregation by measure. This greatly place the preapproved vaccine order. reduces the time spent by quality staff manipulating 4T he  C ommonwealth F und Exhibit 1. Daily Tracking Report Source: NorthShore University Health System, 2009. Electronic flow sheets were created for each key required documentation, reducing the need to reprocess process to standardize care and document compliance records before their submission to CMS. Most of these with standards, ensuring the right information is improvements make use of automated prompts that are evaluated and the care plan is accessible (Exhibit 3). switched off only when documentation requirements For example, one flow sheet guides nurses through are met. a set of preoperative questions pertaining to beta The EHR also provides decision support to blocker use; another coaches them through smoking doctors by alerting them when orders are missed or assessment and education. Providing further value, the wrong choice is made. Hospital administrators are these flow charts incorporate the precise wording of aware that sending too many alerts might desensitize Exhibit 2. Vaccine Navigator Source: NorthShore University Health System, 2009. N orth S hore U niversity H ealth S ystem 5 Exhibit 3. Flow Sheet for Discharge Planning Source: NorthShore University Health System, 2009. doctors to them, a condition known as “alert fatigue.” care, in order to reduce potentially avoidable readmis- Thus, there is only one alert related to the core mea- sions. Recently, NorthShore has begun redesigning its sures—on vaccine prescribing—currently in use. Other discharge process. According to the hospital’s baseline alerts are related to drug interactions, drug allergies, report on readmission rates from CMS, its starting point and duplicate orders. is about equal to the national average. Continuity of Care and Discharge Planning Results NorthShore has had success in meeting the discharge NorthShore made rapid improvement on core measure care standards, though hospital leaders acknowl- scores, achieving exemplary performance in 2007 and edge that there is further work to be done to address early 2008 (Exhibit 4). patients’ comprehensive needs. To date, the greatest Exhibits 5, 6, and 7 illustrate the path improvement has come from assigning case manag- NorthShore has taken to achieve these high scores. ers to each nursing unit. During daily rounds, a case For each set of measures, NorthShore’s performance manager identifies patients whose care falls under the far exceeds the national average and is similar to their new guidelines to ensure all elements of their care are preferred benchmark, created by the Association of met, focusing particularly on discharge instructions American Medical Colleges. and follow-up appointments. Patients receive detailed In Exhibit 5, the percentage of patients whose discharge instructions outlining the next steps in their care was consistent with the pneumonia core measures care. Since this process has been in place, compliance is displayed. Starting out at just 72 percent in July with an important measure—percentage of heart attack 2006, compliance averaged 99 percent in the first six patients given beta blockers at discharge—has risen to months of 2008. NorthShore leaders credit this sub- 100 percent. Administrators believe patients and fami- stantial improvement to the introduction of the Vaccine lies are more aware of how their care will continue out- Navigator, nurses’ active participation in concurrent side the hospital. However, according to Kharasch, just monitoring of patient care, and system-wide education. because a patient has a follow-up plan does not mean Heart attack care was closer to achieving he or she can, or will, follow it. More needs to be done high performance when measurement began in 2006 to educate patients and facilitate appropriate follow-up (Exhibit 6). At the start of the measurement period, 6T he  C ommonwealth F und Exhibit 4. NorthShore’s Scores on CMS Core Measures Compared with State and National Averages National Illinois Indicator Average Average NorthShore Heart Failure Percent of heart failure patients given discharge instructions 71% 77% 97% of 586 patients Percent of heart failure patients given an evaluation of left ventricular systolic (LVS) 87 92 100% of 842 patients function Percent of heart failure patients given ACE inhibitor or ARB for LVS dysfunction 88 87 96% of 200 patients Percent of heart failure patients given smoking cessation advice/counseling 90 92 99% of 72 patients Pneumonia Percent of pneumonia patients given oxygenation assessment 99 99 100% of 744 patients Percent of pneumonia assessment patients assessed and given pneumococcal 80 77 98% of 766 patients vaccination Percent of pneumonia patients whose initial emergency room blood culture was 90 91 98% of 661 patients performed prior to the administration of the first hospital dose of antibiotics Percent of pneumonia patients given smoking cessation advice/ counseling 87 88 100% of 93 patients Percent of pneumonia patients given initial antibiotics within six hours after arrival 93 93 99% of 610 patients Percent of pneumonia patients given the most appropriate initial antibiotic(s) 87 87 98% of 337 patients Percent of pneumonia patients assessed and given influenza vaccination 79 76 98% of 470 patients Heart Attack Percent of heart attack patients given aspirin at arrival 94 92 100% of 510 patients Percent of heart attack patients given aspirin at discharge 91 90 100% of 504 patients Percent of heart attack patients given ACE inhibitor or ARB for left ventricular systolic 89 86 99% of 80 patients dysfunction (LVSD) Percent of heart attack patients given smoking cessation advice/counseling 93 90 99% of 81 patients Percent of heart attack patients given beta blocker at discharge 92 93 100% of 513 patients Percent of heart attack patients given fibrinolytic medication within 30 minutes of arrival 41 34 0% of 1 patient Percent of heart attack patients given PCI within 90 minutes of arrival 70 67 83% of 64 patients Surgical Care Improvement/Surgical Infection Prevention Percent of surgery patients who received preventative antibiotics one hour before incision 85 86 98% of 1777 patients Percent of surgery patients who received the appropriate preventative antibiotics for their 92 93 99% of 1787 patients surgery Percent of surgery patients whose preventative antibiotics are stopped within 24 hours 83 81 98% of 1729 patients after surgery Percent of all heart surgery patients whose blood glucose is kept under good control in 86 90 98% of 53 patients the days right after surgery Percent of surgery patients needing hair removal from the surgical area before surgery, 95 96 100% of 568 patients who had hair removed using a safe method (electric clippers or hair removal cream, not razor) Percent of surgery patients whose doctors ordered treatments to prevent blood clots 82 84 99% of 1615 patients (venous thromboembolism) after certain types of surgeries Percent of patients who received treatment to prevent blood clots within 24 hours before 79 80 99% of 1615 patients or after selected surgeries Note: At the time NorthShore was selected for inclusion in the study, 24 process-of-care measures were used as the criteria. Currently, the 25 measures shown here have become the standard, thus this table includes newer data. ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blockers; LVS = left ventricular systolic; PCI = percutaneous coronary intervention. Data are more recent than the data used in the selection criteria. Source: www.hospitalcompare.hhs.gov. Data are from April 2007 to March 2008. N orth S hore U niversity H ealth S ystem 7 Exhibit 5. Pneumonia Core Measure Composite Performance Percentage compliant 100 90 80 System-wide education provided to front line providers 70 Nursing Concurrent 60 Vaccine Navigator Monitoring (vaccine built in EPIC administration) 50 40 NorthShore University HealthSystem Composite 30 National average composite 20 “ABC” top 10% composite 10 0 July-06 Aug-06 Sep-96 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Monthly performance Note: ABC = “Achievable Benchmark Composite” as defined by the Association of American Medical Colleges. Average monthly sample size = 104 patients. Source: NorthShore University Health System, 2009. about 91 percent of patients received care meeting Exhibit 7, on heart failure care, illustrates a all of the acute myocardial infarction (AMI) stan- similar story of improvement with the introduction of dards. After creating a process improvement team for concurrent monitoring, including having nurses coun- reducing door-to-balloon time and a second team for sel patients on smoking cessation and discuss discharge one-pager activation of the care team, there was more plans. Since NorthShore’s system-wide educational ini- variability but no real improvement. However, the tiative, care processes have largely met the standards. introduction of concurrent monitoring of patient care coincided with an upward trend in achievement across Lessons Learned all of the AMI measures. NorthShore recently joined Elements of NorthShore’s quality improvement jour- a regional improvement program called Lifeline in an ney follow a pattern seen in other case studies in this effort to further reduce its door-to-balloon time. series on high-performing hospitals in process-of-care Exhibit 6. Acute Myocardial Infarction Core Measure Composite Performance Percentage compliant 100 90 80 Nursing concurrent 70 One-pager activation monitoring (all measures) 60 of door-to-balloon 50 team Door-to-balloon 40 team established NorthShore University HealthSystem composite 30 National average composite 20 “ABC” top 10% composite 10 0 July-06 Aug-06 Sep-96 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Monthly performance Note: ABC = “Achievable Benchmark Composite” as defined by the Association of American Medical Colleges. Average monthly sample size = 52 patients. Source: NorthShore University Health System, 2009. 8T he  C ommonwealth F und Exhibit 7. Heart Failure Core Measure Composite Performance Percentage compliant 100 90 80 Systemwide education provided 70 to frontline providers 60 Nursing concurrent monitoring (smoking and 50 discharge instructions) 40 30 NorthShore University HealthSystem Composite 20 National average composite 10 “ABC” top 10% composite 0 July-06 Aug-06 Sep-96 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Monthly performance Note: ABC = “Achievable Benchmark Composite” as defined by the Association of American Medical Colleges. Average monthly sample size = 76 patients. Source: NorthShore University Health System, 2009. measures: quality education, involvement of multidis- For More Information ciplinary staff, process redesign, concurrent review and For more information about NorthShore University measurement, and improvement. As in other hospitals, Health System’s quality improvement strategies, con- day-to-day success is dependent on the diligence of the tact: Liz Behrens, R.N., M.S.N., vice president of qual- nursing department. ity improvement, or Maureen Kharasch, R.N., M.S.N., The improvement process helped to build director of quality and patient safety, NorthShore bridges between the quality department and the clini- University Health System. Current core measure cal staff. Clinicians had not trusted the quality staff on results are posted on the organization’s Web site issues related to compliance and documentation. But (www.northshore.org) in the Quality and Patient Safety through physicians’ direct communications with CMS Folder in the “About Us” section. about the core measures, sharing of concurrent data, and teamwork, their relationship improved and trust grew. Subsequently, physicians, nurses, and pharma- cists took on leadership roles in achieving compliance with core measures. Now, improvements are driven not just by the quality department, but throughout the hos- pital by clinical and non-clinical staff. NorthShore also learned that their staff were willing to use new systems, as long as they were acces- sible, actionable, and did not create additional burdens at the bedside. The EHR system made patients’ infor- mation accessible and useful—facilitating delivery of care through prompts, flags, and other reminders for nurses, physicians, and pharmacists. Most important, giving clinicians real-time feedback about their patients has raised performance to a higher level. N orth S hore U niversity H ealth S ystem 9 N otes 1 This study was based on publicly available infor- mation and self-reported data provided by the case study institution. The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, 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 organizations’ experi- ences in ways that may aid their own efforts to become high performers. 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. 2 Quality data for Northshore University Healthcare is reported on WhyNottheBest.org and HospitalCompare under the former name of the institution, Evanston Northwestern Healthcare. 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 used 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 improvement. 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 N orth S hore U niversity H ealth S ystem 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 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=Q netPublic%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 Jennifer N. 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 Care 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 Liz Behrens and Maureen Kharasch for generously sharing their time, knowledge, information, and materials with us, as well as other members of the quality department who provided data and figures for this case study. 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.