How one system spread gains from its flagship to its community hospitals
After successfully reducing average length of stay (LOS) at its flagship hospital, Carilion Clinic set out to do something many health systems attempt, but few achieve: replicate a successful intervention across a diverse set of regional facilities. The result is a case study in the power and the challenge of operational systemness.
Systemness refers to the degree to which a health system functions as an integrated, cohesive whole, rather than a collection of independent sites operating under one corporate banner. For Carilion, a $3 billion revenue, seven-hospital system based in Roanoke, VA, it became the framework that enabled performance improvement to take root at its flagship hospital and then cascade across its entire network.
The journey began in 2021 at Carilion Roanoke Memorial Hospital (CRMH), where LOS had been climbing. This created bottlenecks that led to downstream issues with emergency department (ED) boarding, transfer acceptance and patient throughput. Like many systems during and after the Covid-19 pandemic, Carilion was dealing with disrupted processes, strained capacity and an urgent need to restore both access and trust for its patients.
In response, hospital leaders worked with advisors from Claro Healthcare, now part of Kaufman Hall, a Vizient company, to launch a structured improvement initiative that combined redesigned patient status determination, strengthened case management and greater discipline and attention to throughput strategies. Despite leadership changes and external strain, the initiative produced measurable results: average LOS dropped by more than half a day and observation rates fell by 4.5 percentage points, exceeding initial performance goals.
The endeavor was driven by foundational change‑management practices. It emphasized multidisciplinary collaboration, with engaged physician leadership and robust nursing and ancillary staff accountability. Frequent face‑to‑face consensus building and transparent communication, including an easily accessible dashboard tracking LOS, anchored the effort. Staff reinforced improvements until they became self‑sustaining. CRMH relieved the bottleneck pressure, created room to accept transfers and reduced avoidable patient days.
Extending gains across the system
The results at CRMH indicated to system leaders that the intervention should be scaled. With momentum from the initial success, the system saw an opportunity to broaden the impact. The system includes six regional hospitals of varying size and complexity, including two critical access hospitals. Each has its own history, leadership style and culture.
Scaling the initial initiative’s success hinged on standardization, but not uniformity. Carilion leveraged CRMH’s playbook as a framework, then adapted it for the realities of each site. Key actions included:
- Service line leadership: System leaders, ED and hospitalist leaders were aligned across hospitals, creating consistency in expectations and communication.
- Process replication: Daily interdisciplinary rounds were standardized systemwide, bringing together nursing, case management, physicians and support services to proactively manage progression of care consistently.
- Data enablement: The dashboard originally built for CRMH was made accessible at all sites. Leaders across departments and all multiple levels were trained to use it to track LOS, identify outliers and drive accountability.
- Cultural adaptation: Rather than prescribing change from the top down, the system approached each hospital with a combination of standardized expectations and local flexibility. There was initial skepticism, but a shared belief in the objective kept resistance minimal. A key shift occurred when local leaders saw their performance reflected in shared dashboards. The use of key performance indicators monitored by red-yellow-green metrics sparked motivation and even a bit of healthy competition.
The results varied by facility but were consistently positive. LOS reductions were achieved across the regional hospitals, in some cases reaching record low levels. Financially, the system recaptured capacity, reduced reliance on external transfers and unlocked access for patients who would otherwise have left the network.
Operationally, clinicians benefited from greater predictability. With aligned workflows across hospitals, it became easier to staff across locations and orient new team members. At the executive level, system leaders could compare performance using a common lens and focus on key performance indicators before issues escalate.
Applying the lessons
A few lessons from Carilion Clinic’s experiences can be gleaned for health systems seeking to spread performance gains across diverse care settings:
- Start with one. Begin at one facility. Identify which one would benefit most from dedicated improvement efforts, and make sure it has the support to undertake a pilot project. Establish proof of concept and create the playbook for the system.
- Think big. It is easier to scale down to smaller facilities than it is to scale up to larger ones.
- Codify your principles but allow for flexibility. Identify the practices that must remain consistent across sites, then build room for adaptation where needed.
- Invest in infrastructure. Dashboards, workflows and governance structures are critical. Build systems that sustain themselves.
- Sequence matters. Carilion didn’t go systemwide overnight. It built and refined before it scaled. That sequencing helped ensure readiness and eased anxiety at each step.
Enabling success
The initiative also had an effect beyond improving access to care. Once relationships, tools and expectations were in place, other improvement efforts gained traction. Systemness became the expectation.
Carilion’s experience offers insights for systems navigating similar challenges. Among the most important enablers:
- A clear system identity. The system already emphasized shared accountability and cross-hospital collaboration. The throughput work built on that identity rather than trying to impose it.
- Executive sponsorship. Leadership across finance, operations and clinical domains aligned early and sustained that alignment over time.
- Physician and nursing engagement. Trusted peers delivered the message at each site. It started with nursing and physician leaders and cascaded from there. This credibility helped mitigate resistance and foster buy-in.
- Data visibility. The LOS dashboards became a shared source of truth. As leaders at different sites began to manage to the same metrics, behavior shifted.
- Adaptability. While the principles of success remained constant, the implementation was tailored. Smaller hospitals weren’t asked to mimic CRMH in every detail. Instead, they adopted the core practices in ways that respected their size, staffing and culture.
While Carilion’s access to care and throughput initiative was undertaken to achieve operational improvements, it accomplished more than that. It reinforced a culture of shared purpose, evidence-based decision-making and intentional collaboration. It showed that systemness is a capability, not just a concept; and when harnessed correctly, systemness delivers measurable impact.
Acknowledgements: The authors would like to thank Paul Davenport of Carilion Clinic for his insights, reviews and comments on this topic.
