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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.