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A Guide to Achieving High Performance in Multi-Hospital Health Systems

Multi-hospital health system leaders have a significant impact on the quality of health care in the United States. The 200 largest hospital systems (a hospital system being defined as having 2 or more general acute care hospitals) account for over half of all hospital admissions in the United States.

Through generous support from The Commonwealth Fund, the Health Research & Educational Trust (HRET) embarked on a project to identify and disseminate best practices associated with high performing health systems. Through the use of publicly available quality data, interviews with leaders of 45 multi-hospital health systems, and analysis, identified below are three major themes, four major best practice categories and seventeen specific best practices that are associated with high performance.

Major Themes


1. No one system type was most associated with high performance


We examined the relationships of many system characteristics to an overall composite measure of quality as well as to more specific measures, such as the HQA core measures, overall patient satisfaction, and a combined, risk-adjusted readmission rate and mortality rate. From the analysis, it was evident that high quality scores were achieved by a variety of different system types—large or small systems, geographically regional or multi-regional systems, systems from all regions of the country, and systems with differing levels of teaching components.


 2. No one factor was clearly associated with high performance

Over 50 system factors that might distinguish between top performing systems and those with lower quality scores were analyzed, and no one factor clearly separated the top systems from the others. In every single case, factors that were observable in high performing systems also existed in at least some of the lower performing systems. Moreover, there was no unanimity among top performing systems with respect to factors associated with high performance. As discussed in this guide, success depends on a range of actions. 


 3. Creating a culture of performance excellence, accountability for results, and leadership execution are the keys to success

From the study, a culture of performance excellence and accountability for results was strongly exhibited during the interviews with the high performing health systems. This was best defined through cultural markers such as: focusing on continuous improvement, driving towards dramatic improvement or perfection versus incremental change, emphasizing patient-centeredness, adopting a philosophy that embraces internal and external transparency with regard to performance, and a having a clear set of defined values and expectations that form the basis for accountability of results. The other finding connected with the culture of performance excellence was a disciplined and persistent focus by leadership on execution and implementation to achieve the lofty goals. The culture of performance and excellence was strongly connected to leadership’s execution doctrine.

Best Practices Associated with High Performing, Multi-Hospital Health Systems




 1. Establish a System-wide Strategic Plan with Measurable Goals

    A. Set both measurable short and long-term goals.

    B. Set goals for quality and safety based on the pursuit of perfection rather than improvement. 

    C. Link the system’s quality goals with its operational and financial goals.

A system-wide strategic plan for quality and safety with measurable goals across multiple dimensions is a best practice for improving system performance. Many systems also establish threshold, stretch, and (in some cases) high stretch goals. They then track the progress of achieving these through frequently using system performance dashboards.











 2. Create Alignment Across the Health System with Goals and Incentives

    A. Establish system-level quality steering/oversight committees to provide direction to system leaders in setting system-wide goals and aligning them with all hospitals. 


    B. Embed health system goals into individual hospital leaders’ goals.

    C. Link annual bonuses for system and hospital leaders to performance targets in the system’s key strategic areas.

    D. Align incentive pay and/or accountability for achieving system-level quality and patient safety targets into contracts with physicians.

    E. Align emphasis on culture with efforts to understand and improve it.

Aligning the system’s quality and safety goals with the goals of the individual hospitals as well as the hospital leaders’ is a practice used by top performing systems to improve system performance. Having highly aligned goals facilitates performance tracking and reporting across multiple hospitals and promotes standardization in performance measurement. Additionally, aligning performance incentives (financial or other) for system and hospital executives with the system’s strategic goals (e.g., quality, patient satisfaction, financial) is a strategy top performing systems use to improve overall performance.


3. Leverage Data and Measurement Across the Organization

    A. Use an “all or none" or “perfect care” approach to set targets for all performance measures.

    B. Consider setting targets based upon event counts (numerator) as well as rates.

   C. Share dashboards with hospital leaders and staff frequently to identify areas in need of improvement and then take immediate actions to get back on track.

   D. Post dashboard information on the system’s intranet.

   E. Engage in national benchmarking initiatives to achieve greater transparency as well as foster healthy competition between hospitals.

   F. Utilize corporate support through data mining of existing information systems, frequent analyses, and reporting of measures for hospital-level performance improvement. 

High performing systems use dashboards (e.g., a balanced scorecard) to measure and manage system performance. Setting system-level targets within each strategic priority area is also a strategy used by top performing systems to improve performance across hospitals. Additionally, sharing system dashboards regularly with hospital leaders, clinicians, and other staff helps promote quality improvement and accountability.


 4. Standardize and Spread Best Practices Across the Health System

    A. Establish a process to identify and select practices for standardization.

    B. Use ongoing education and skills development to spread best practices. 

    C. Effectively disseminate best practices across the system.

In order to successfully adopt best practices, the standardization of care processes and the use of education and skills development programs are vital in the spread of best practices as well as the acceleration of their use among the entire health system.

Multi-hospital health system leaders can employ a variety of practices to improve care across their multi-facility organizations that focus upon overall system improvement. However, the keys to success are not the specific practices themselves, but the execution of those practices and the creation of a culture that supports performance improvement.


Publication Details



J. Yonek., S. Hines., and M. Joshi,  A Guide to Achieving High Performance in Multi-Hospital Health Systems, Health Research & Educational Trust, March 2010.