Abstract
This paper describes our observations, findings, and understanding of Shouldice Hospital, an 89-bed hospital with five operating rooms, specializing in the surgical repair of abdominal wall hernias and recurrent hernias. For more than 75 years, the hospital has been offering not only efficient and low-cost services for patients and payers but also high-quality hernia repair with a lifetime guarantee, outstanding patient experience and caregiver satisfaction. Our purpose is to explain a mystery: accounting for the success of Shouldice as a modern, well-managed health care organization able to achieve the quadruple performance problem.