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The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms.

An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA.

The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions.

This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms.

Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

The purpose of this paper is to describe how a fractal-based quality management infrastructure could benefit quality improvement (QI) and patient safety efforts in health care.

The premise for this infrastructure comes from the QI work with health care professionals and organizations. The authors used the fractal structure system in a health system initiative, a statewide collaborative, and several countrywide efforts to improve quality of care. It is responsive to coordination theory and this infrastructure is responsive to coordination theory and repeats specific characteristics at every level of an organization, with vertical and horizontal connections among these levels to establish system-wide interdependence.

The fractal system infrastructure helped a health system achieve 96 percent compliance on national core measures, and helped intensive care units across the USA, Spain, and England to reduce central line-associated bloodstream infections.

The fractal system approach organizes workers around common goals, links all hospital levels and, supports peer learning and accountability, grounds solutions in local wisdom, and effectively uses available resources.

The fractal structure helps health care organizations meet their social and ethical obligations as learning organizations to provide the highest possible quality of care and safety for patients using their services.

The concept of deliberately creating an infrastructure to manage QI and patient safety work and support organizational learning is new to health care. This paper clearly describes how to create a fractal infrastructure that can scale up or down to a department, hospital, health system, state, or country.

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