The U.S. health care delivery system faces serious challenges such as an increasing demand for services due to an aging population, unhealthy lifestyles, growth in the number of uninsured individuals, and an increase in chronic diseases. At the same time, the system has to cope with a limited supply of money, physicians, and nurses inferior quality of care delivered by U.S. hospitals. While the U.S. hospital industry is adapting to address these issues, not much progress in improving the quality of care delivered has been made over the last decade. However, theories exist that management systems, organizational traits, and leadership are key factors for hospitals to improve quality of care outcomes. This study takes a holistic look at these factors to identify and analyze critical drivers for better quality of care outcomes of U.S. hospitals. The study also aims to identify differences between chief executive officers' (CEOs) leadership traits among lean (mediocre performance), high (top 20th percentile), and low performing (bottom 20th percentile) U.S. hospitals in regards to their quality of care measures.

Two separate online surveys were conducted. The first online survey was targeted at all 4,697 U.S. hospitals that are required to disclose quality of care measures to the Federal government. Results of this first survey revealed that two management system factors drive quality of care outcomes of U.S. hospitals. Furthermore, findings also show that critical access hospitals have a lower quality of care performance than acute care hospitals. Thus, based on the results from this survey, we concluded that management system factors are main drivers of hospital performance, whereas organizational trait and leadership factors did not significantly contribute to hospital performance.

A second survey to CEOs and CEO followers in 9 selected hospitals found significant differences between CEO traits leading lean and low performing hospitals, and, to a lesser degree, significant differences among high and low performing hospitals. However, the study did not find any significant differences in CEO traits between lean and high performing hospitals. Findings also include that some management system factors differed significantly between lean and high performing hospitals, but no evidence for such differences could be found between lean and high and high and low performing hospitals, respectively. These results suggest that management systems and CEO leadership traits play an important role in determining U.S. hospital performance as measured by their quality of care.