2017 Award Recipient

Adventist Health Castle

Highlights

• AHC boasts rates from below 1 percent to zero for 

common hospital-acquired infections, as well as patient 

falls. AHC has been a top performer nationally for having 

had zero CAUTI infections in its inpatient units for the last 

3 years and 5 months. AHC’s ICU is performing in the top 

10 percent of ICUs nationwide, with a CLABSI rate of zero 

for four of the last five years.

• AHC has met or surpassed top-quartile levels on 

composite measures of patient safety, evidence-based care, 

and mortality related to its clinical care processes. 

• For the past three years, AHC has performed in the top 

3 percent of the nation’s health care organizations for 

inpatient care results reported to the Centers for Medicare 

and Medicaid Services for Value-Based Purchasing.

• AHC’s levels of physician engagement are in the top 

10 percent of national results. For three Gallup survey 

questions that are considered key dimensions of physician 

engagement—in which respondents are asked about the 

health care organization for safety, as a place to practice 

medicine, and for quality of care—AHC is currently in 

the 95th, 97th, and 97th percentiles, respectively, on 

these measures.

 

Adventist Health Castle (AHC) is a community hospital system that 

provides inpatient and outpatient care to people who primarily live 

on the windward side of the Hawaiian island of O’ahu. It is one 

of 20 hospitals within the nonprofit, faith-based, Adventist Health 

system headquartered in Roseville, CA. Employing 1,046 people, 

AHC has a main hospital in Kailua, HI, and two professional centers 

and a rural health clinic. AHC’s services include 24-hour emergency 

care, inpatient acute care, the Vera Zilber Birth Center, a Joint 

Care Center, inpatient behavioral health services, multi-specialty 

surgical services, cardiovascular services, neurological services, 

the Hawaii Center for Metabolic and Bariatric Surgery, outpatient 

services, chemotherapy clinic, imaging services, and the Wellness 

and Lifestyle Medicine Center.

A Tenacious Pursuit of Quality Improvement

• Adventist Health Castle demonstrates a tenacious pursuit of quality 

improvement for the benefit of its customers, “chasing zero” harm 

to its patients. As a result, it boasts rates from below 1 percent to 

zero for common hospital-acquired infections (i.e., catheterassociated urinary tract infections (CAUTI), central-lineassociated blood stream infections (CLABSI), surgical site 

infections [SSI], and Clostridium difficile bacterial infections), 

as well as patient falls. AHC has been a top performer 

nationally for having had zero CAUTI infections in its 

inpatient units for the last 3 years and 5 months. AHC’s ICU is 

performing in the top 10 percent of ICUs nationwide, with a 

CLABSI rate of zero for four of the last five years.

• Benchmarking its performance against high-performing U.S. 

hospitals in Premier Inc.’s Quest data-sharing collaborative, 

AHC has met or surpassed top-quartile levels—improving its 

performance by 12 percent from 2014 to 2016—on composite 

measures of patient safety, evidence-based care, and mortality 

related to its clinical care processes. AHC’s rates of compliance 

for evidence-based practices to improve outcomes for venous 

thromboembolism, stroke, and sepsis, as well as elective delivery 

guidelines for AHC Birth Center patients, have achieved or 

surpassed top 10 percent performance levels in national 

comparisons in recent years.

• AHC interactions with patients and other customers are guided 

by the organization’s embrace of the Hawaiian spirit of aloha 

(which means love) and ohana (family). AHC clinical and 

associate employees communicate and build relationships with 

patients and other customers through such practices as rounding, 

share cards, care boards, and a service recovery program. 

• Demonstrating the faith-based organization’s identified core 

competency of “Love matters,” AHC’s patient satisfaction results 

(as measured by third-party-administered surveys on health care 

providers and services) are in the top 25 percent or better of 

national comparisons, with many in the top 10 percent.

Baldrige Performance Excellence Program • National Institute of Standards and Technology • Department of Commerce 
Mission-Focused and Accountable Leadership

• Senior leaders engage employees and foster a workforce culture 

promoting engagement and high performance through a variety of

systematic communications with physicians, associate staff

members, volunteers, patients, community, and suppliers and 

partners. For example, senior leaders conduct regular visits of

hospital departments and personally present awards and write 

thank-you notes to employees and volunteers. Targeted 

communications include a magazine for physicians and discussions 

at Medical Executive Committee meetings. As a result, measures 

of senior leaders’ engagement of employees show exemplary 

performance levels and trends.

• AHC’s senior leaders and governing board members are held 

accountable for their performance through an annual evaluation

process that is integrated with the organization’s strategic plan and 

budget process. All leaders and managers (from the CEO to frontline

directors) are continuously measured and held accountable for 

strategic objectives and enterprise-level metrics through the tracking 

of 90-day action items in their individual Leadership Evaluation 

Manager plans. 

• The Joint Commission (TJC) annual assessments of accountability 

measures show that AHC has far surpassed a composite 

requirement of 85 percent, achieving above 99.5 percent and thus 

earning recognition as TJC’s top performer on key quality measures 

for the last three years.

Strong Financial and Market Performance

• For the past three years, AHC has performed in the top 3 percent 

of the nation’s health care organizations for inpatient care results 

reported to the Centers for Medicare and Medicaid Services (CMS) 

for Value-Based Purchasing, in which reimbursement increases for 

higher-quality care on a set of core measures. This high performance 

has contributed to the nonprofit organization’s operating margin of 

approximately $2 million.

High Employee Engagement and a Focus on 

Caring and Wellness

• AHC’s results for overall workforce engagement surpass 

the performance of all other facilities in the Adventist Health 

system and meet or exceed the top quartile of Gallup national 

comparison data. In addition, AHC results show year-overyear increases in volunteer hours and volunteer satisfaction 

levels above 80 percent.

• AHC’s levels of physician engagement are in the top decile 

of national results. For three Gallup survey questions that 

are considered key dimensions of physician engagement—in

which respondents are asked about the health care organization 

for safety, as a place to practice medicine, and for quality of 

care—AHC is currently in the 95th, 97th, and 97th percentiles,

respectively, on these measures.

• Reflecting practices and policies that promote wellness and 

safety (e.g., reduced health insurance premiums for employees 

who actively participate in the organization’s wellness 

program and an all-vegetarian cafeteria for employees), AHC 

was designated “Healthiest Place to Work in Hawaii” by Pacific 

Business News, earned the American Heart Association’s Fit 

Friendly Gold Award, and became the first Blue Zone employer 

in the state of Hawaii. In addition, AHC health care workers’ 

vaccination rates surpass benchmarks and the Healthy People 

2020 goal of the Centers for Disease Control and Prevention.

Providing for Community Needs

• AHC’s vision is to transform health care experiences by improving

the physical, mental, and spiritual health of its community

members. The organization manages people’s health to help

make care more affordable through an ongoing transition from a

fee-for-service model to a focus on population health, with a

related investment in promoting community wellness. Besides 

offering a wide range of outreach services such as health 

education and wellness classes, AHC provides community-based 

primary care in an underserved area of the island through its rural 

health clinic.

• AHC demonstrates top-decile results in National Committee 

for Quality Assurance comparisons for disease prevention and 

treatment programs, sustaining performance for measures of

its charitable contributions, community wellness offerings, and 

attributed life growth. AHC has managed (attributed through 

primary care physicians) 33 thousand lives saved from annual 

and necessary screening, prevention, and wellness activities.

• Driven by its mission and vision—and regardless of financial 

gain or loss—the medical center operates one of only two 

inpatient behavioral health units on the island to help meet 

the community’s mental health needs.

2017 Award Recipient

Adventist Health Castle 

For more information:

Adventist Health Castle

640 Ulukahiki Street

Kailua, HI 96734

RodrigJ2@ah.org

www.adventisthealth.org/castle/pages/castle-home.aspx

Baldrige Performance Excellence Program

The Baldrige Program educates organizations of all sizes and 

from all sectors in organizational performance management and 

improvement. We also administer the Malcolm Baldrige National

Quality Award. Our key services are to identify and recognize 

role-model organizations, share best management practices, 

and help organizations achieve best-in-class performance levels.

We are the only public-private partnership and Presidential award 

program dedicated to improving U.S. organizations. 

For more information on Baldrige, visit www.nist.gov/baldrige,

call (301) 975-2036, or email us at baldrige@nist.gov.

Baldrige Performance Excellence Program • National Institute of Standards and Technology • Department of Commerce