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Creating a fractal-based quality management infrastructure

Peter J Pronovost (Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA)
Jill A Marsteller (Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA)

Journal of Health Organization and Management

ISSN: 1477-7266

Article publication date: 18 August 2014




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.

Practical implications

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.

Social implications

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.



The authors thank Christine G. Holzmueller, BLA for editing the manuscript.


Pronovost, P.J. and Marsteller, J.A. (2014), "Creating a fractal-based quality management infrastructure", Journal of Health Organization and Management, Vol. 28 No. 4, pp. 576-586.



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