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The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety.

Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes.

The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model.

This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors’ knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.

Early writings about teamwork in healthcare emphasized that healthcare providers needed to evolve from a team of experts into an expert team. This is no longer enough. As patients, accreditation bodies, and regulators increasingly demand that care is coordinated, safe, of high quality, and efficient, it is clear that healthcare organizations increasingly must function and learn not only as expert teams but also as expert multiteam systems (MTSs).

In this chapter, we offer a portrait of the robust, and albeit complex, multiteam structures that many healthcare systems are developing in order to adapt to rapid changes in regulatory and financial pressures while simultaneously improving patient safety, quality, and performance.

The notion of continuous improvement rooted in continuous learning has been embraced as a battle cry from the boardroom to the bedside, and the MTS concept offers a meaningful lens through which we can begin to understand, study, and improve these complex organizational systems dedicated to tackling some of the most important goals of our time.

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.

To describe peer learning and shared accountability and their use within our management system to improve the rate of patient annual wellness visits completed by primary care physicians.

Our management system implements programs to improve performance on a measure, initially declaring the goal, roles and responsibilities. In the illustrative case in this article, primary care physicians are assigned the goal of completing annual wellness visits for 65% of their patients by the end of 2021. To support physicians, peer learning networks are established, connecting teams, physicians and others to broadly share best practices and support better performance. Shared accountability means higher-level leaders in the organization need to first set lower-level leaders up to succeed before holding lower-level leaders accountable for achieving the declared goal. Our shared accountability model describes processes of the higher-level leader to ensure lower-leader success. The accountability process if a lower-level leader does not improve performance involves 3 steps: (1) a letter; (2) meeting with hospital executives for peer review; (3) review for sanctions/disciplinary action.

In quarter 1 of calendar year 2021, we identified 30 physicians that were behind pace for reaching the 65% goal of AWVs with patients for 2021 and also had not achieved the 2020 60% goal. After step 1, 22 of 30 (73%) physicians were on target for the goal. After step 2, 3 of 8 physicians were on target for the goal.

Peer learning and shared accountability are underdeveloped in health care, and often viewed as at odds with each other. In our framework we integrate them. Thus, we formed learning networks, connecting every level of the organization and branching out across the health system to share ideas and build capability. Our shared accountability model removes the punitive connotation often connected to accountability by aligning higher and lower-level leaders to work together as a team. This model is improving personal performance among primary care physicians, and now being used for all quality and value efforts in our health system. We believe if broadly applied, this model could help improve value in health care.

The purpose of this study is to demonstrate how action learning can be practically applied to quality and safety challenges at a large academic medical health system and become fundamentally integrated with an institution’s broader approach to quality and safety.

The authors describe how the fundamental principles of action learning have been applied to advancing quality and safety in health care at a large academic medical institution. The authors provide an academic contextualization of action learning in health care and then transition to how this concept can be practically applied to quality and safety by providing detailing examples at the unit, cross-functional and executive levels.

The authors describe three unique approaches to applying action learning in the comprehensive unit-based safety program, clinical communities and the quality management infrastructure. These examples, individually, provide discrete ways to integrate action learning in the advancement of quality and safety. However, more importantly when combined, they represent how action learning can form the basis of a learning health system around quality and safety.

This study represents the broadest description of action learning applied to the quality and safety literature in health care and provides detailed examples of its use in a real-world context.

This chapter considers the usefulness and validity of public inquiries as a source of data and preliminary interpretation for case study research. Using two contrasting examples – the Bristol Inquiry into excess deaths in a children’s cardiac surgery unit and the Woolf Inquiry into a breakdown of governance at the London School of Economics (LSE) – I show how academics can draw fruitfully on, and develop further analysis from, the raw datasets, published summaries and formal judgements of public inquiries.

Academic analysis of public inquiries can take two broad forms, corresponding to the two main approaches to individual case study defined by Stake: instrumental (selecting the public inquiry on the basis of pre-defined theoretical features and using the material to develop and test theoretical propositions) and intrinsic (selecting the public inquiry on the basis of the particular topic addressed and using the material to explore questions about what was going on and why).

The advantages of a public inquiry as a data source for case study research typically include a clear and uncontested focus of inquiry; the breadth and richness of the dataset collected; the exceptional level of support available for the tasks of transcribing, indexing, collating, summarising and so on; and the expert interpretations and insights of the inquiry’s chair (with which the researcher may or may not agree). A significant disadvantage is that whilst the dataset collected for a public inquiry is typically ‘rich’, it has usually been collected under far from ideal research conditions. Hence, while public inquiries provide a potentially rich resource for researchers, those who seek to use public inquiry data for research must justify their choice on both ethical and scientific grounds.

This paper aims to determine whether the rank order of hospitals changes when their central line‐associated bloodstream infection (CLABSI) rate is computed using a traditional proxy measure for the denominator (number of patients with one or more catheter in place) versus using the actual number of catheters or catheter‐lumens.

The authors conducted a statewide voluntary one‐day prevalence survey among all hospitals participating in Washington State's mandatory public reporting program. Hospitals counted the number of catheters and catheter‐lumens as well as patients with catheters. Counts of patients with one or more catheter in place, of catheters, and of catheter‐lumens were extracted from each hospital's completed survey form and transformed into a ratio. Three CLABSI incidence density rates were computed for each hospital by scaling their annual CLABSI rate in the previous calendar year by the ratio of patients to catheters to catheter‐lumens. Influence of these three different denominators on rank order of the hospitals was assessed by scaling the corresponding Centers for Disease Control and Prevention's National Healthcare Safety Network incidence density rates for each participating hospital and examining position shifts with the Wilcoxon signed rank test.

Statistically significant but only modest shifts in position became evident, which did not correlate with service complexity characteristics of the hospitals affected.

Others have shown that the CLABSI incidence density rate in a single hospital is significantly affected by switching from a traditional proxy measure denominator to a more meaningful denominator. This is the first report on whether all hospitals' rates would be affected in a uniform or a non‐uniform manner if a different denominator were to be selected by mandatory public reporting programs.

Strategic decisions leaders make involving organizational changes such as mergers and acquisitions (M&A), divestitures, and downsizing, which can influence and/or interact with other organizational factors. For example, within the context of M&A, changes impact financial performance, firm behaviors, and organizational culture. In addition, strategic decisions for these types of change can also interrelate with other more intrapersonal factors, including both leaders’ and employees’ health and well-being. Employee stress, also referred to as “merger syndrome,” outlines individual negative impacts of the changes including, but not limited to, cynicism and distrust, change wariness, and burnout, all accumulating to psychological effects including increases in detachment to work, stress, and sick leave. In this chapter, the authors outline the different impacts M&A phases have on stress and well-being and how they interrelate with the strategic decisions leaders make. The authors also outline future research opportunities and practical implications for how leaders and employees could better manage future major changes such as M&A activities.