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Journal Article


From Striving to Thriving: Systems Thinking, Strategy, and the Performance of Safety Net Hospitals



The Issue

Safety-net hospitals play a vital role in caring for the uninsured and underinsured, yet many of these facilities struggle to remain financially viable. Despite the challenges inherent in running a safety-net hospital, some are prospering. Leading researchers explored the organizational characteristics of these higher-performing institutions.


What the Study Found

By contrasting the characteristics of six high-performing safety-net hospitals with three low-performers, Commonwealth Fund–supported researchers found that the high-performers excelled at:

  • coordinating patient flow across the continuum of care to avoid duplication of services, reduce emergency department use, improve post-discharge care, and increase access to primary care services;
  • engaging in partnerships, especially with nonhospital providers such as federally qualified health centers and long-term care facilities, to improve care coordination and share the burden of treating uninsured and underinsured patients;
  • playing to strengths, by providing services only in areas in which they excel and using partnerships to fill gaps in the care continuum; and
  • investing in human capital.



Strategic management, more so than structural characteristics, plays a critical role in thriving safety-net hospitals. Those that prosper have an understanding of the full spectrum of patient needs, seek partners to complement their operations, and limit services to those in which their organizations perform well.

Publication Details



J. Clark, S. Singer, N. Kane et al., "From Striving to Thriving: Systems Thinking, Strategy, and the Performance of Safety Net Hospitals," Health Care Management Review, published online May 25, 2012.