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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 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.

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.

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.

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 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.

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.

The purpose of this paper is to introduce the first new hospital accreditation option in over 40 years, and the only accreditation scheme for US hospitals which is ISO‐based. It seeks to explore factors prompting design of a fundamentally new approach, patient and provider experiences thus far, outlook for adoption of this alternative, and potential for improving delivery of health services in US hospitals.

The approach takes the form of a review of available materials, industry and popular press accounts, federal documents; interviews with hospital executives and managers and with prime developers of the new accreditation process; access to personal prior industry research and experiences.

Frustrated by an established accreditation process seen as wasteful and ancillary to standard operations, administrators and clinicians developed a new approach designed to use accreditation as a strategic business tool to reinforce clinical and business process integration, efficiencies, innovation, accountability, and sustained improvement in day‐to‐day hospital operations. The accreditation process has been approved for hospitals providing care to US Medicare beneficiaries.

Pressures to reform the financing and delivery of health services in the USA – and to address concerns of escalating costs, decreased access, limited improvements in patient safety, poor care coordination, and an absence of accountability – intensify. The introduction of a novel hospital accreditation option into an arena long dominated by a single powerful accreditor provides opportunity for disruptive innovation. The rate of adoption of this new approach and its impact on existing challenges will be of interest to multiple stakeholders.

This paper seeks to describe a recent impasse resulting from failure of a federal oversight agency to distinguish between observational studies documenting the impact of quality improvement activities versus experimental clinical trials research.

This paper provides a review of popular press accounts, regulations, and relevant correspondence; and interviews with project leaders.

A controversial federal decision in the USA quickly galvanized unusually harsh criticism from a very wide range of professional associations, healthcare researchers, and patient safety advocacy groups.

This incident, at a time when application of quality improvement methods and public reporting networks are becoming more widespread in healthcare, illustrates the urgent need for better distinction between clinical trials research versus quality improvement research projects. Institutional review boards are ill‐advised to apply familiar ethical safeguard reviews appropriate to the former to the latter.

The purpose of this paper is to compare and contrast traditional data collection methodologies employed in health care with more practical observational methods which are closely aligned with Lean thinking. When combined with problem solving, observational approaches achieve demonstrable improvements in clinical outcomes, productivity and efficiency. The paper aims to describe the changes in mindset and behaviour that are required to adopt the observational methods.

The approach is to describe and evaluate case study examples on the use of observational data in the National Health Service in the UK. This is then used to derive generic principles about the wider application of observational data in health care.

Traditional data collection methodologies are often insufficient to expose the root cause of a problem and therefore may result in little or no action. The observational methods identify the root cause and as such offer a much more practical and real‐time way of solving process‐related problems.

The observational methods of collecting data described here offer staff at all levels of the organisation practical approaches to preventing mistakes and errors in health care processes.

The case studies described here support the reintroduction of observational techniques used by the early pioneers of productivity. The originality of the paper is in the use of these observational methods in a wide range of clinical settings to provoke changes in working practices.