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Public Hospital Case Study Series: Introduction

Compared with other hospitals, public hospitals are generally assumed to face multiple barriers to providing high-quality care: lower revenues; sicker patients who may have infrequent contact with the health care system; and an older infrastructure, particularly related to health information technology.

This case study series set out to find how some public hospitals have succeeded in achieving excellence in quality of care, in spite of such challenges. We sought to understand the strategies and factors that contribute to high performance, as well as the barriers and challenges public hospitals face. To do so, researchers examined aggregate quality scores on 23 process-of-care measures reported by CMS, for all hospitals submitting data from July 2007 through June 2008. They selected for case study analysis eight public hospitals from among 14 that performed among the top 10 percent of more than 2,000 public and private hospitals reporting during this period.

For the purposes of this series, we defined "public hospital" as any government-owned hospital or member of the National Association of Public Hospitals. Because of data limitations, neither payer mix nor other definitions of "safety net" status was used in the selection process.

Four of the best-performing public hospitals examined in one case study are members of the Memorial Health System in Florida. These hospitals scored within the top 5 percent of public and private hospitals on the process-of-care, or "core," measures. Another case study examines three public hospitals that are members of the Carolinas Health System; they scored within the top 10 percent of public and private hospitals. A third case study examines Norman Regional Hospital in Oklahoma, which scored in the top 5 percent among public and private hospitals. Other selection criteria are detailed in the individual case studies.

The key findings from this series of case studies are:

  • Some public hospitals have been able to achieve quality scores comparable to the best hospitals in the country, though on average, public hospitals score slightly worse than private hospitals.
  • All three case study hospitals or health systems are owned by their local government and have been their local "safety net" entity for over 50 years. Over time, all have diversified to provide other health services and added additional hospital sites.
  • Only Norman Regional Hospital does not receive any local public funds. Carolinas Health System received $16.7 million in 2007, and Memorial Health System received $725 million in 2009.
  • Lessons for public hospital managers are much the same as the lessons gleaned from leaders of private hospitals. Leaders at these three institutions made strong commitments of time (their own and that of their leadership teams) to quality improvement. They strived to create a culture in which frontline workers felt personally responsible for the quality of care their patients received. They backed up their commitment with resources to enable data collection as well as performance tracking and reporting.
  • These three hospitals and systems were about on par with the other, privately owned case study hospitals in implementing electronic health record systems. Careful planning, not lack of resources, is influencing the pace of their implementation of health information technology.

These case studies' findings are not meant to generalize to all publicly owned hospitals, many of which face different financial pressures related to disproportionately high rates of uninsured and Medicaid patients, and/or sick patients who do not have regular sources of primary and preventive care. The case studies do illustrate that publicly owned hospitals may fulfill their commitment to serve all patients in the community while pursuing—and attaining—the highest measures of health care quality.

Publication Details



S. Silow-Carroll, Public Hospital Case Studies Series: Introduction, The Commonwealth Fund, July 2010.