Case Study High-Performing Health Care Organization • March 2009 November 2009 Kettering and Sycamore Medical Centers: Committing Resources to Surgical Quality Jennifer N. Edwards, Dr.P.H., and Aimee Lashbrook, J.D., M.H.S.A. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance Location: Kettering and Miamisburg, Ohio health care system. The Fund carries out this mandate by supporting Type: Private, not-for-profit teaching hospitals independent research on health care Beds: Kettering Medical Center–481; Sycamore Medical Center–181 issues and making grants to improve Distinction: Both hospitals, part of the Kettering Health Network, scored in the top 3 percent in health care practice and policy. Support composite of five surgical care improvement process-of-care measures among more than 2,300 for this research was provided by hospitals (more than half of U.S. acute-care hospitals) eligible for the analysis. The Commonwealth Fund. The views presented here are those of the authors Timeframe: April 2007 through March 2008. See Appendix for full methodology. and not necessarily those of The This case study describes the strategies and factors that appear to contribute to high performance Commonwealth Fund or its directors, on surgical care improvement measures at Kettering and Sycamore Medical Centers. It is based officers, or staff. on information obtained from interviews with key hospital personnel and materials provided by the Kettering Health Network during April and May 2009.      For more information about this study, Summary please contact: In early 2000, the Hospital Quality Alliance (HQA) developed process-of-care Jennifer N. Edwards, Dr.P.H. Health Management Associates measures to encourage hospitals to deliver evidence-based treatment in four clin- jedwards@healthmanagement.com ical areas—heart attack, heart failure, pneumonia, and surgical care. As part of their participation in the Hospital Quality Incentive Demonstration, Kettering Health Network’s (KHN) hospitals began preparing for data reporting in early To download this publication and 2003, and the first year of data (2004) showed that all KHN hospitals were learn about others as they become available, visit us online at among the top performers on all of the process-of-care, or “core” measures. This www.commonwealthfund.org and case study focuses on performance on the five surgical care improvement project register to receive Fund e-Alerts. (SCIP) measures collected and reported by the Centers for Medicare and Commonwealth Fund pub. 1334 Vol. 31 Medicaid Services (CMS) in 2007 and 2008.1 Two of the network’s hospitals, 2 T he  C ommonwealth F und Kettering Medical Center and Sycamore Medical importance of involving bedside nurses in process Center, scored among the top 3 percent of U.S. hospi- design, education, and performance improvement tals on the five surgical measures: activity—they are the most important link to the results we are achieving.” • Percent of surgery patients who received pre- In addition, the hospitals have focused on ventative antibiotic(s) one hour before incision national quality initiatives, such as achieving Nursing • Percent of surgery patients who received the Magnet status and the Malcolm Baldrige National appropriate preventative antibiotic(s) for their Quality Award.2 surgery The biggest change at the two hospitals in recent years was the introduction of concurrent quality • Percent of surgery patients whose preventative monitoring and feedback to providers and managers. antibiotic(s) are stopped within 24 hours after The use of real-time data—on patients who are still in surgery the hospital—has inspired competition and greater • Percent of surgery patients whose doctors accountability among physicians and nurses, resulting ordered treatments to prevent blood clots in near-perfect compliance with recommended surgical (venous thromboembolism) for certain types processes. of surgeries • Percent of surgery patients who received treat- ORGANIZATION ment to prevent blood clots within 24 hours Kettering Medical Center is the flagship hospital of the before or after selected surgeries Kettering Health Network. It is a 481-bed facility located in Kettering, just outside Dayton, Ohio. This case study also discusses Kettering and Sycamore Medical Center is a 183-bed hospital in the Sycamore’s performance on two other surgical care Dayton suburb of Miamisburg. Kettering and measures, for which CMS began reporting data this Sycamore collaborate closely, including sharing a year. The measures were not part of the selection crite- quality management team and a surgical care improve- ria for this case study. ment workgroup. The other hospitals in the health sys- tem are Grandview Medical Center, Southview • Percent of all heart surgery patients whose Medical Center, and Greene Memorial Hospital, all of blood sugar (blood glucose) is kept under which share Kettering Health Network’s mission and good control in the days right after surgery goals but have separate quality improvement staff. The • Percent of surgery patients needing hair system also owns an inpatient behavioral health facil- removed from the surgical area before surgery, ity, multiple outpatient facilities, a physician group, who had hair removed using a safer method and a research institute. The parent organization is (electric clippers or hair removal cream– Kettering Adventist HealthCare, which is affiliated not a razor) with the Seventh-day Adventist denomination. Leaders at both Kettering and Sycamore attri- NETWORK-WIDE STRATEGIES bute their success to having made investments in staff. Kettering Health Network’s journey to becoming a In 2005, Liz Wise, R.N., then vice president for clinical high-quality organization dates to 1994, when Frank quality at Kettering and Sycamore, developed a quality Perez, M.H.A., FACHE, was hired as chief executive department shared among the two hospitals. Further, officer. Perez brought with him a passion for quality the hospitals have made nurses key to their improve- improvement, which led to the system’s investment in ment strategy. Chris Turner, M.S., R.N., current vice staff and processes to promote and improve the quality president for clinical quality at Kettering and Sycamore of care. Medical Centers, said, “I cannot stress enough the K ettering and S ycamore M edical C enters : C ommitting R esources to S urgical Q uality 3 Committing Ample Resources SURGICAL CARE IMPROVEMENT STRATEGIES According to Rebekah Wang, M.D., FACP, when she Quality improvement at Kettering and Sycamore joined Kettering Health Network in September 2007 as Medical Centers is driven by concurrent review of per- medical director for clinical quality the health system formance data, promotion of evidence-based practices, was already “resource rich.” More than 100 people and data feedback to providers. Kettering and were working to promote the quality agenda, including Sycamore’s shared quality department relies on two a decision support group, infection control staff, case electronic support systems: MIDAS and PICIS. managers, social workers, clinical documentation spe- MIDAS has a module for online event reporting that cialists, patient relations staff, accreditation and regu- enables staff to quickly and easily report a patient latory compliance staff, and medical and surgical clini- safety event, such as an adverse drug reaction, patient cal outcomes teams. Many more hospital staff served fall, medication error, “never” event (e.g., wrong-site on teams devoted to particular improvement initiatives. surgery or retained foreign object), operating room Wang also found that the network’s low mortal- (OR) procedural complication, or other aberration ity rate, costs, and length of stay were exemplary. She from best practice. PICIS is an OR electronic system attributes the system’s enviable performance on both used by the circulating nurse to input details of surgi- cost and quality to its participation in the CMS/ cal care, such as the timing of antibiotic administration Premier pay-for-performance demonstration, starting and of incision, both of which are related to CMS sur- in 2004, and in QUEST, a national quality benchmark- gical care measures. In 2010, EPIC will be imple- ing initiative of Premier Healthcare. Sycamore was a mented at all of the Kettering Health Network hospi- founding member of the QUEST initiative in 2007.3 tals; this fully integrated electronic health record sys- Even though surgical care plays a minor role in these tem will further facilitate clinical decision support and initiatives, they helped create a platform for the hospi- performance monitoring. tals’ surgical improvement work. The Institute for Performance improvement efforts in surgery Healthcare Improvement’s national surgical care rely on these same strategies and tools. The clinical improvement listserv has enabled the hospitals to share operations director of perioperative services at lessons and discuss challenges with other organizations. Sycamore, Kyle Kalbaugh, R.N., plays a crucial role in setting expectations for excellence, developing Recognizing Superior Performance teamwork in the OR suite, and ensuring that education Hospital leaders write notes and deliver personal mes- occurs on a consistent basis. As new core measures are sages in order to express their appreciation for staff introduced, Kalbaugh works closely with quality staff members’ hard work, believing that such recognition to set standards and design better care processes, and fosters personal commitment to quality improvement. then uses the plan-do-check-act cycle to determine The inverse is also true: staff who do not meet the net- which changes are valuable and which have no effect work’s standards are counseled about their performance. on the quality of care. Kettering Health System also recognizes suc- cess through its Excellence for Life program. Last Evidence-Driven Change year, eight teams earned awards, including the Wang shares with physicians the latest evidence on Opportunity for Improvement team and the Core best care practices and changes to the core measure Measures Process Improvement team. specifications and works with them to design improve- ments. She attends section meetings (e.g. for cardio- thoracic surgery, urology, hospitalists, anesthesiology), distributes copies of relevant research studies, and 4T he  C ommonwealth F und shows surgeons and internists both group and individ- late, the provider would have been counseled and the ual outcomes data on the surgical measures. variance noted and tracked. Once a process improvement is accepted Monitoring and reporting on variances was through this clinical review process, quality improve- valuable, but did not result in the marked improvement ment staff disseminate the new standard and educate that staff and leadership sought. Wise challenged the staff about its use. Order sets are created specifying quality staff to reduce variances by 50 percent com- each component of a patient’s care, and chart review pared with 2007 levels. Beginning in January 2008, a specialists conduct concurrent reviews to assess com- new strategy that heightened the level of attention and pliance with the new standard. response to variances from recommended care was “When they understand the rationale behind the implemented. Now, when clinical document specialists practice and see the need for improvement in our sta- identify a variance, they immediately send an e-mail to tistics, they become personally invested in making notify several hospital personnel, including clinicians, changes,” Wang says. To keep track of best surgical managers, and quality specialists. The nurse manager practices, she relies on published literature, CMS and is required to respond to the OFI team with details Agency for Healthcare Research and Quality reports, about the circumstances, and then Wang contacts the Institute for Healthcare Improvement and QUEST ini- clinicians to discuss the deviation. If a pattern of vari- tiatives, and her staff. ances is detected by virtue of multiple e-mails in a day Eventually, a protocol is developed to hardwire or a week, it may be discussed the next day during the new care practice.4 “We try to make it easy for all daily “huddles,” or rounds. staff to deliver the best care,” says Wang. From start to In addition to the immediate alerts, Susie Peil, finish, a process improvement can be designed, tested, R.N., clinical data analyst at Kettering, sends a weekly and put forward for adoption in as little as six to eight report to all nursing units, clinical nurse managers, weeks and then audited to measure its effects. nursing clinical directors, and service line leaders at both hospitals summarizing the variances from the Concurrent Review core measures that occurred during the previous week. From mid-2005 through January 2008, Kettering and This enables staff to identify problems and track trends Sycamore tested the use of concurrent review to iden- in performance. Peil also generates a monthly report tify variances from CMS core measures. Clinical doc- showing rolling 12-month performance rates. umentation specialists—nurses with many years of This system of review and accountability has surgical or ICU experience—reviewed patient charts to been effective in lowering variances. By the end of see if core measures were being met. They discussed 2008, variances from surgical care measures were 60 and reported variances from the standards with clinical percent lower than in the first six months of 2007, nurse managers on the units where they occurred in an exceeding Wise’s target. As of August 2009, Sycamore effort to educate staff and possibly improve care experiences an average of 1.25 variances a month, or before patients were discharged. Some variances (also three per 100 surgical cases, and Kettering has 8.6 called opportunities for improvement, or OFIs) could variances a month, or four per 100 surgical cases be remedied while patients were still hospitalized. (based on a 12-month rolling average). Of these, about Some were time sensitive and could not be corrected, a third were able to be remedied before patients left but still provided a learning opportunity. For example, the hospital, and about two-thirds were either reported if the preoperative antibiotic was not started within as a failure or ultimately deemed not eligible for one hour of incision time because a surgeon arrived reporting. K ettering and S ycamore M edical C enters : C ommitting R esources to S urgical Q uality 5 In addition to the attention by managers, vari- a single dose of antibiotics and found this was as effec- ances are reviewed retrospectively by the SCIP tive in controlling infection as numerous doses and, Improvement Process Group, which is co-chaired by further, reduced the likelihood of patients developing Beverly Schneider and Karen Gorby, R.N., M.S.N., antibiotic resistance to the clostridium difficile bacte- M.BA., Kettering Medical Center’s director of surgery, ria. The hospitals’ Pharmacy and Therapeutics and meets every other month. They look for opportuni- Committee approved reducing the number of antibiotic ties to change the way care is delivered to ensure qual- administrations from three to two, and eventually to ity goals are met. For example, after noting that sur- one—a change that will avoid the possibility of admin- geons sometimes ordered the wrong preoperative anti- istering antibiotics more than 24 hours after surgery biotic for a procedure, Wang and Schneider put circu- and reduce the risk of antibiotic resistance. However, lating nurses in charge of preoperative antibiotic selec- physicians are still reluctant to make this change. tion, based on the SCIP antibiotic table. This new pro- cess was presented to the OR Committee and approved Clipping Practices by the Medical Executive Committee. Since beginning One of the new HQA surgical care measures monitors this process in the spring of 2009, variances for antibi- the method of hair removal prior to surgery; use of otic selection have decreased. clippers, rather than razors, has been shown to reduce infection rates. At Sycamore, razors were removed Practice Improvements from the ORs, but some surgeons continued to bring Antibiotic Selection and Timing their own. These surgeons were counseled by their Three of the HQA surgical measures relate to the clinical leaders and eventually conformed to practice choice and timing of antibiotics administration. standards. Kettering had one recalcitrant physician Kettering and Sycamore followed the improvement who ultimately accepted the new policy as well. process described above—using research and data col- Glucose Control lection—to convince clinicians to standardize their Another new surgical measure monitors appropriate antibiotic choices and administration processes. This management of blood glucose level after surgery, in led to the development of a standard order set for anti- order to decrease the risk of infection. Kettering biotic administration. Nearly all physicians now use Medical Center had been appropriately managing sur- this order set, though they can make different choices gical patients’ glucose levels over the 18-month period if they document the reason for doing so. proceeding March 2009. Then in March 2009, two In a recent review of six months of variance patients experienced elevated glucose levels after sur- reports, 96.5 percent of 1,322 patients received all gery, and the SCIP team could not identify the causes. appropriate antibiotic administration. Among the 48 Wang used the national SCIP listserv to solicit sugges- patients (3.5%) who did not, the most frequent error tions for ways to control glucose levels, and she is cur- was failure to discontinue antibiotics within 24 hours rently discussing these strategies with the nurses. of surgery. Quality staff noted that giving three doses of antibiotics, each spaced eight hours apart, can prove Normothermia challenging. If for example a surgery ends late in the Keeping surgery patients at the appropriate tempera­ evening, the first postoperative dose might be given ture, called normothermia, has been shown to reduce later than expected and the last dose would then be incidence of wound infection. Beginning in October given after the 24-hour time frame. Wang introduced 2009, CMS requires hospitals to report compliance information from the national SCIP listserv showing with normothermia measures for all patients, rather that other hospitals had experimented with giving just than only colorectal patients, as hospitals had been 6T he  C ommonwealth F und doing previously. Sycamore and Kettering have rou- Local papers have written about the health tinely measured postoperative temperatures on all system’s performance on CMS measures, likely patients and are thus well positioned to meet this new leading physicians in the community to send their care standard. patients to Sycamore and Kettering. Both medical centers also have achieved recognition from local Results and national organizations. Sycamore and Kettering both exceed state and national The Ohio Partnership for Excellence, the state standards on all surgical process-of-care measures. Baldrige quality program, gave Kettering Health Exhibit 1 displays the most recent year of data for both Network the 2009 Gold Level Award, a recognition hospitals on the surgical measures, including the two for organizations that have demonstrated significant newest ones. progress toward excellent performance. Organizations Exhibits 2 and 3 show trends over time at recognized at this level must demonstrate results Kettering and Sycamore for surgical care “bundles”. that are directly attributable to deployment of a The bundles combine several measures; a patient has systematic approach. to have received appropriate care for each measure in the bundle in order for the hospital to receive credit for that bundle. Exhibit 1. Sycamore Medical Center and Kettering Medical Center Scores on Surgical Care Improvement Core Measures Compared with State and National Averages Surgical Care Improvement Indicator National Ohio Sycamore Kettering Average Average Medical Center Medical Center Percent of surgery patients who were given an antibiotic at the right time (within one hour before 87% 90% 98% of 262 patients 99% of 2,001 patients surgery) to help prevent infection Percent of surgery patients who were given the 93% 95% 98% of 264 patients 99% of 2,021 patients right kind of antibiotic to help prevent infection Percent of surgery patients whose preventative antibiotics were stopped at the right time (within 24 86% 88% 100% of 244 patients 99% of 1,914 patients hours after surgery) Percent of all heart surgery patients whose blood glucose is kept under good control in the days right 84% 86% 0 patients 99% of 244 patients after surgery Percent of surgery patients needing hair removal from the surgical area before surgery, who had 100% of 2,174 95% 98% 100% of 304 patients hair removed using a safe method (electric patients clippers or hair removal cream, not razor) Percent of surgery patients whose doctors ordered 100% of 1,852 treatments to prevent blood clots after certain 86% 90% 98% of 361 patients patients types of surgeries Percent of surgery patients who got treatment at the right time (within 24 hours before or after their 83% 88% 97% of 361 patients 99% of 1,852 patients surgery) to help prevent blood clots after certain types of surgery Source: www.hospitalcompare.hhs.gov. Data are from October 2007 through September 2008. K ettering and S ycamore M edical C enters : C ommitting R esources to S urgical Q uality 7 Exhibit 2. Kettering SCIP Improvement 3Q06–1Q09 Core SCIP/SIP-1-2-3 All-or-none bundle Core SCIP Infection 1–7 All-or-none bundle Core SCIP ALL measures All-or-none bundle 100 80 60 40 20 0 Jul-Sep Oct- Jan- Apr- Jul-Sep Oct- Jan- Apr- Jul-Sep Oct- Jan- 2006 Dec Mar Jun 2007 Dec Mar Jun 2008 Dec Mar 2006 2007 2007 2007 2008 2008 2008 2009 Source: Quality Department, Kettering Health System, May 2009. Notes: “Core SCIP1-2-3” includes the three antibiotics measures. “All-or-none” means that care is considered compliant only if all three care processes were delivered. “Core SCIP Infection 1–7” includes the antibiotic measures as well as blood glucose monitoring, appropriate hair removal, and normothermia. Only patients who receive all care processes are counted as successes. “Core SCIP ALL measures” includes 1–7 plus the measures of β-blocker therapy and receipt of venous thromboembolism (VTE) prophylaxis before and after surgery. Challenges and Lessons Learned might take the following lessons from Sycamore’s and The breadth and volume of staff resources Sycamore Kettering’s experience: and Kettering have committed to quality measurement and improvement has likely contributed to the hospi- • Having adequate staff members devoted to tals’ progress over the last two years. Hospitals seek- measuring, improving, and monitoring care ing to improve their performance on surgical measures processes, and who work well as a team, is essential. Exhibit 3. Sycamore SCIP Improvement 3Q06–1Q09 Core SCIP/SIP-1-2-3 All-or-none bundle Core SCIP Infection 1–7 All-or-none bundle Core SCIP ALL measures All-or-none bundle 100 80 60 40 20 0 Jul-Sep Oct- Jan- Apr- Jul-Sep Oct- Jan- Apr- Jul-Sep Oct- Jan- 2006 Dec Mar Jun 2007 Dec Mar Jun 2008 Dec Mar 2006 2007 2007 2007 2008 2008 2008 2009 Notes: “Core SCIP1-2-3” includes the three antibiotics measures. “All-or-none” means that care is considered compliant only if all three care processes were delivered. “Core SCIP Infection 1–7” includes the antibiotic measures as well as blood glucose monitoring, appropriate hair removal, and normothermia. Only patients who receive all care processes are counted as successes. “Core SCIP ALL measures” includes 1–7 plus the measures of β-blocker therapy and receipt of venous thromboembolism (VTE) prophylaxis before and after surgery. Source: Quality Department, Kettering Health System, May 2009. 8T he  C ommonwealth F und • Medical directors can engage surgeons in the Kettering and Sycamore face challenges in sus- improvement process by educating them about taining and building on their records of high perfor- the CMS requirements and the medical litera- mance. Implementation of an enterprise electronic ture on evidence-based care, and by providing health record system throughout the Kettering Health them with information about their performance. System will require staff to learn new processes for collecting and charting data, though in the long run • Concurrent review of care processes, including such a system should produce better processes for prompt notification of all involved parties and tracking performance. responses from managers, can dramatically improve performance. For More Information • Coaching, counseling, and educating are key For further information, contact Rebekah Wang, to engaging staff in quality improvement. A M.D., medical director for clinical quality, Kettering punitive approach will result in resentment and Sycamore Medical Centers, (937) 395–8891. and fear. N otes 4 A protocol provides direction through each step of a patient’s care, depending on his or her progress. For 1 The CMS Web site, Hospital Compare, uses the example, a protocol can describe criteria for wean- name “Kettering Medical Center – Sycamore” in ing a patient from a ventilator. By contrast, an order reference to Sycamore Medical Center. Hospital set includes fixed instructions that are not altered Compare also reports the hospital size as 120 beds, based on a patient’s condition. while Sycamore Medical Center reports 183 beds. 5 Two additional surgical care improvement measures 2 Magnet status is an award given by the American were added in 2007 but were not included in the Nurses’ Credentialing Center, an affiliate of the composite score for selection purposes because data American Nurses Association, to hospitals that sat- were not available for four quarters. isfy a set of criteria designed to measure the strength and quality of their nursing. The Malcolm Baldrige National Quality Award is an annual award that recognizes U.S. organizations in the business, health care, education, and nonprofit sectors for perfor- mance excellence. 3 The CMS/Premier Hospital Quality Incentive Dem- onstration rewards high quality of inpatient care by awarding bonus Medicare payments to hospitals in several clinical areas and by reporting performance data on the CMS Web site, Hospital Compare. QUEST is a voluntary, nationwide collaborative aimed at improving the quality and efficiency of hospital care. See premierinc.com/quality-safety/ tools-services/quest/index.jsp. K ettering and S ycamore M edical C enters : C ommitting R esources to S urgical Q uality 9 Appendix. Selection Methodology Selection of high-performing hospitals for this series of case studies on surgical care is based on data submitted by hospitals to the Centers for Medicare and Medicaid Services. We use five measures that are publicly available on the U.S. Department of Health and Human Services’ Hospital Compare Web site, (www.hospitalcompare.hhs.gov). The measures, developed by the Hospital Quality Alliance, relate to practices in surgical care. Surgical Care Improvement Process-of-Care Measures 1. Percent of surgery patients who received preventative antibiotic(s) one hour before incision 2. Percent of surgery patients who received the appropriate preventative antibiotic(s) for their surgery 3. Percent of surgery patients whose preventative antibiotic(s) are stopped within 24 hours after surgery 4. Percent of surgery patients whose doctors ordered treatments to prevent blood clots (venous thromboembolism) for certain types of surgeries 5. Percent of surgery patients who received treatment to prevent blood clots within 24 hours before or after selected surgeries The analysis uses all-payer data from April 2007 through March 2008. To be included, a hospital must have submitted data for all five measures (even if data submitted were based on zero cases), with a minimum of 30 cases for at least one measure, over four quarters.5 Approximately 2,300 facilities—more than half of U.S. 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 surgical care improvement process-of-care measures was the primary cri- teria for selection in this series, the hospitals also had to meet the following criteria: not a government-owned hospi- tal, at least 50 beds, not a specialty hospital, 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 the 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. 10T he  C ommonwealth F und 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. Aimee Lashbrook, J.D., M.H.S.A., is a senior consultant in Health Management Associates’ Lansing, Mich., office. Ms. Lashbrook has six years of experience working in the health care industry with hospitals, managed care organizations, and state Medicaid programs. She provides ongoing technical assistance to state Medicaid programs, and has played a key role in the development and implementation of new programs and initiatives. Since joining HMA in 2006, she has conducted research on a variety of health care topics. Aimee earned a juris doctor degree at Loyola University Chicago School of Law and a master of health services administration degree at the University of Michigan. A cknowledgments We wish to thank Rebekah Wang, M.D., for her time and insights. We also wish to thank Mary Ann Gregor, M.B.A., coordinator, clinical decision support, and Susie Peil, R.N. B.S., clinical data analyst, for their assistance with data used in 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.