In 1999, the Institute Of Medicine asked Fortune 500 companies to apply their knowledge of quality improvement to health care. The Leapfrog Group, representing Fortune 500 companies, was formed. In 2003, its three established program standards: (a) implementation of computerized physician order entry software (CPOE); (b) staffing of intensive care units with physicians trained in critical care medicine (IPS): and (c) referral of patients to hospitals meeting a specified volume of identified procedures or specialty services (EBHR) were introduced to Massachusetts hospitals.

Two Massachusetts hospitals reporting excellent progress and two hospitals reporting fair progress in achieving these goals were selected to study program implementation, using an embedded, multiple case study design (Yin, 2003). Semi-structured interviews were conducted with administrators, physicians, pharmacists and information technology (IT) specialists to assess: (a) resources; (b) inter-organizational communication; (c) economic, social, political and external conditions; (d) hospital characteristics; and (e) the disposition of the implementers. Propositions were formulated based upon public policy implementation theory (Van Meter and Van Horn, 1975) and then evaluated with explanation building analysis (Yin, 2004). The intensity of the response by hospitals to the Leapfrog Group standards was determined by frequency of the interviewees' responses and amount of change required to implement this program.

The characteristics of these hospitals were the most significant factor related to the degree of program implementation achieved. Differences in implementation are attributed to the access they have to financial and human resources as well as the degree of change required. Value of the program's standards plus networking opportunities with other hospitals are credited for the progress made. CPOE implementation is hindered at hospitals staffed with physicians with admitting privileges and facilitated at hospitals staffed with physicians employed by the hospital. Pharmacists and IT specialists value the CPOE standard because it is part of the electronic health record which is a goal of each of the hospitals within this study. The value of CPOE implementation creates the impetus for implementing this standard; however physician resistance slows the progress made by hospitals.