What are the strategic processes used to make hospital capital investment decisions in an era of patient safety and quality improvement? The investigators hypothesized that current capital investment needs could result in segmentation of the hospital sector. This segmentation could create a group of hospitals that can afford improvements, a group of hospitals that will struggle to make modest improvements and a group of hospitals that will be left behind. The researchers 1) identified current capital positions of hospitals; 2) identified hospital-spending priorities given the competing needs of hospitals; 3) determined how capital investment decisions will be made and considerations/tradeoffs used to make these decisions; 4) identified planning processes being used at hospitals for future quality and safety infrastructure needs; and 5) identified current sources of capital financing and expected sources in the future. The objective of this study was to inform decision-makers of the array of options and best practices in hospital capital strategies; the current sources of capital financing; potential impending problems and worst case scenarios; and various approaches to quality and safety infrastructure development and financing. The researchers conducted an extensive literature review, a nationally representative survey of hospital CEOs, an analysis of combined financial and survey data and targeted interviews.