INTRODUCTION The hospital is a 130-bed, non-profit acute care facility that is part of an 18-member purchasing alliance of community hospitals, and is located in the Appalachian region of the United States. Over the past four years the hospital has seen a 40% decline in total joint replacement surgeries; a significant number of patients chose to go to hospitals in the city 60 miles away for what they perceive to be better care. This decline ha

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