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What quality improvement strategies are the leaders of our nation's prominent public hospitals following at this critical time of American health care change? Even more burdened than community hospitals with care for the uninsured and immigrant populations and with scarcer resources, how can they prosper, let alone survive? At the Spring 2007 annual meeting of the National Association of Public Hospitals in Boston, we talked with five leaders (Table 1) and found surprising and hopeful answers, and offer this conversation so that we can learn from them and follow their lead.    Table 1  The participants    The Permanente Journal (TPJ): Please briefly introduce yourself, your position, and give a brief description of your hospital health system.  Sandral Hullett, MD (SH): Cooper Green Mercy Hospital is a small community hospital in the medical center affiliated with the University of Alabama at Birmingham, so we are a teaching facility. About 70% of the patients are uninsured; the other 30% are Medicaid, Medicare, and third party. We are a service provider for a large number of disadvantaged people. Fifty percent of our funding is from an indigent county tax. We've been there since 1972 and have been primarily a source for acute care though we are changing our image through more community-based work.  Gene Marie O'Connell, RN, MS (GO): San Francisco General Hospital (SFGH) is the only trauma center in the city, with a full array of services in the acute care hospital as well as primary care and specialties, and the only psychiatric emergency unit in the city with the most psychiatric and mental health services of any area hospital. We have a total of 550 beds. Through an affiliation with University of California, San Francisco, we provide a third of all the teaching for the university. Last year we saw over 100,000 unduplicated clients.  John W Buford, III (JB): Truman Medical Center (TMC)—a 501-C3, nonprofit entity that was originally the city hospital—is a two-hospital system that includes a long-term care facility, as well as a major behavioral health offering, and we oversee the Jackson County Public Health Department.  Alan D Aviles (AA): The New York City Health and Hospitals Corporation is the largest municipal health system in the country. We serve about 1.3 million New Yorkers every year, including about 400,000 uninsured. The system includes 11 acute care facilities and 4 long-term care facilities and more than 80 community-based primary care sites. We have 4500 acute care beds and another 3000 long-term care beds. We provide 5 million outpatient visits per year and 1 million emergency room visits per year. We also run a very large Medicaid-managed care plan with more than 275,000 enrollees.

Innovation in Our Nation's Public Hospitals: Interview with Five CEOs and Medical Directors