Best practices among high-performing systems

What distinguishes high-performing multi-hospital health systems from the rest? With support from The Commonwealth Fund, that's what the Health Research & Educational Trust (HRET) set out to uncover in a yearlong research project.1 And their findings? Co-author Maulik S. Joshi, DrPH, president HRET and senior vice president for research at the American Hospital Association, says it isn't that simple. There is not one single characteristic that makes the difference but rather a confluence of systemwide communication of goals and priorities, linking a "perfect care" model with short-term goals, leadership's commitment to improvement, and incentivizing quality care.

"[C]ulture and leadership were clearly the two foundational elements for high performance — having that culture of performance excellence, accountability for results, and leaders really being able to implement and execute on these things were really, really major themes," Joshi says.

Another element common to high-performing systems was clear alignment of plans across the system "so that everything was clear from the top of the health system down to each individual hospital," he says. Other consistent practices seemed to hold true: "Incentives were really built in to do performance improvement and achieve the results. High-performing systems really used data robustly in terms of how they were doing, how they can improve, what to do, and then I think one of the more emerging areas is the standardization and spread [of data]," he says.

Some systems have salaried physicians who receive financial incentives for meeting specified quality and safety goals. Regarding incentivizing staff, Joshi says it is an "enabler" and "definitely plays a factor. [I]t's one of those you call necessary but not sufficient. It enables, but it's not the answer."

Alongside communication throughout the system, articulating and prioritizing goals is integral to high performance. "You need to focus on those vital few things that are most important. Those will vary by organization, but they'll probably have some association with patient satisfaction, clinical quality, access, and other things. So absolutely every organization needs to figure out what's that priority list and stay focused on delivering the best care for those areas and acknowledging that you're not excluding everything else but that you need to always have those few things that are your priority," Joshi says.

Using robust data was one consistent theme among high-performing systems, but Joshi says in many ways being able to access appropriate and useful data is still difficult. "We all are just really in our infancy of having more data and information used, and electronic health records will get us there," he says. "It's just we don't have real-time or near real-time information in health care to help us to decide the best care for our patients sometimes, and so we go on proxies. So I think part of it is, again, the data may be there, the skills are there, but we as a field need to have it readily accessible and usable so we can do something with it, and that's nobody's fault."

Another theme was holding to the quality principle of "all or nothing" or "getting to zero" and creating milestones or shorter-term goals of getting there.

(To download the full report, go to Also see Appendix A: High Performing Health System Survey, page 21.)


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