Cover: Fostering a Commitment to Quality

Fostering a Commitment to Quality

Best Practices in Safety-Net Hospitals

Published in: Journal of Health Care for the Poor and Underserved, v. 27, no. 1, Feb. 2016, p. 293-307

Posted on Mar 14, 2016

by Michael Hochman, Medell Briggs-Malonson, Erin Wilkes, Jonathan Bergman, Lauren Patty Daskivich, Tannaz Moin, Ilanit Brook, Gery W. Ryan, Robert H. Brook, Carol Mangione

Research Questions

  1. What best practices are enabling five high-performing hospital systems—four of which serve safety-net populations—to foster a "culture of quality," in which employees follow quality guidelines, see others taking quality-focused actions, and "feel quality all around them"?
  2. How are these hospitals delivering high-quality, patient-centric care despite limited resources?

Following a series of high-profile quality challenges, the Martin Luther King, Jr.-Harbor (MLK-Harbor) hospital in South Los Angeles was closed in 2007. Prior to its closure, MLK-Harbor was a publicly operated hospital serving a large safety-net population in its community. As one of two major trauma centers in the area, the closure of MLK-Harbor had an immediate impact on the community and resulted in some community members seeking care at hospitals outside of their community. In 2009, the County of Los Angeles and the University of California worked together to open a new, private, non-profit hospital named the Martin Luther King, Jr. Community Hospital (MLKCH) to meet the medical needs of the community (in particular, need for access to specialty, hospital, and emergency care). To assist in this process, a team of Robert Wood Johnson Foundation Clinical Scholars worked with the MLKCH Board of Directors and conducted a series of interviews with high-performing hospital systems to identify best practices for creating and maintaining a culture of quality, including technical quality, interpersonal quality, and efficiency. A key focus of our interviews was on understanding how these institutions used resources efficiently to promote high quality, patient-centric care despite resource limitations. In this document, we summarize our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. These institutions provide important lessons for MLKCH and other safety-net institutions.

Key Findings

Five organizational components were essential to the establishment and maintenance, despite limited resources, of high-quality, patient-centric health care systems:

  • Establishing an explicit shared vision, mission, and set of institutional values that foster a culture dedicated to high-quality, patient-centered care.
  • Hiring and retaining personnel—including executive leadership, physicians, nurses, and other patient-facing staff—who are stewards of quality health care.
  • Promoting efficient resource utilization and implementing management principles that emphasize rigorous problem solving and standardization of work.
  • Developing a well-organized, system-wide quality improvement infrastructure, including high-performing EHR systems, that enables effective real-time monitoring of care processes and outcomes.
  • Cultivating integrated, patient-centered care.


Policymakers should provide guidance and support (including, in some cases, financial resources), to help safety-net institutions develop the systems and processes necessary to deliver high-value care and become a "provider of choice" in their communities. To help safety-net institutions adopt these systems and processes, policymakers might encourage or facilitate direct guidance to these institutions from high-performing hospitals such as those studied here. Additionally, policymakers might create short-term exemptions from some of the financial penalties outlined by the Affordable Care Act for historically low-performing systems.

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