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Creating a Fractal-Based Quality Management Infrastructure Peter J Journal of Health Organization and Management Creating a fractal-based quality management infrastructure Peter J. Pronovost Jill A. Marsteller Article information: To cite this document: Peter J. Pronovost Jill A. Marsteller , (2014),"Creating a fractal-based quality management infrastructure", Journal of Health Organization and Management, Vol. 28 Iss 4 pp. 576 - 586 Permanent link to this document: http://dx.doi.org/10.1108/JHOM-11-2013-0262 Downloaded on: 12 October 2016, At: 05:55 (PT) References: this document contains references to 21 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 477 times since 2014* Users who downloaded this article also downloaded: (2015),"Small but sophisticated: Entrepreneurial marketing and SME approaches to brand management", Journal of Research in Marketing and Entrepreneurship, Vol. 17 Iss 2 pp. 149-164 http://dx.doi.org/10.1108/ JRME-05-2014-0008 (2010),"Going green: women entrepreneurs and the environment", International Journal of Gender and Entrepreneurship, Vol. 2 Iss 3 pp. 245-259 http://dx.doi.org/10.1108/17566261011079233 Access to this document was granted through an Emerald subscription provided by emerald-srm:172729 [] For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Downloaded by JHU Libraries At 05:55 12 October 2016 (PT) Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information. About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download. The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-7266.htm JHOM 28,4 Creating a fractal-based quality management infrastructure Peter J. Pronovost Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, 576 Baltimore, Maryland, USA, and Received 25 November 2013 Jill A. Marsteller Revised 18 March 2014 Health Policy and Management, Accepted 11 April 2014 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Abstract Purpose – 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. Design/methodology/approach – 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. Findings – 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. Originality/value – 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. Keywords Management, Quality improvement, Health and safety, Safety, Health care, Safety measures Downloaded by JHU Libraries At 05:55 12 October 2016 (PT) Paper type Viewpoint Today’s clinicians are asked to attack more and more patient safety issues without receiving additional resources for these tasks. They have improved hospital safety and quality by clocking in extra time and adding tasks, meetings, checks and re-checks, cross-monitoring, and other efforts that are above and beyond their regular duties. Clinicians deeply care about patients, and sincerely want to improve quality and safety. Still, they are crying “uncle” as new demands press them to enhance hospital safety and quality. Many feel they simply cannot add another initiative or program, at least not reliably or sustainably, without more support from their employer (Michtalik et al., 2013). Further, although many in health care realize the need to engage patients in decision Journal of Health Organization and making, there are few mechanisms available to meaningfully tap into patient preferences Management Vol. 28 No. 4, 2014 and ideas. pp. 576-586 r Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-11-2013-0262 The authors thank Christine G. Holzmueller, BLA for editing the manuscript. Most health care organizations have only pieces of the quality infrastructure needed Fractal-based to ensure high quality, safe, patient-centered care and, in the end, patients suffer. quality Frontline workers feel personally accountable and expend significant effort recovering from mistakes, but rarely reduce the risk that the mistake will recur. They rely on management short-term solutions to correct errors, called single-loop learning (Argyris and Scho¨n, infrastructure 1974, 1978) or first-order problem solving (Tucker and Edmondson, 2003), rather than looking for the most effective systems-based solutions, known as double-loop learning 577 (Argyris and Scho¨n, 1974, 1978) or second-order problem solving (Tucker and Edmondson, 2003). Thus, we rarely learn from these mistakes at the system level, failing to reduce the risk that future patients will suffer the same harm. Clinicians and their organizations fail to learn from mistakes for multiple reasons, including an emphasis on individual vigilance within our own sphere of control, tight staffing and parsimony of resources (interest in efficiency), and removal of managers and other non-direct labor support from daily work activities, weakening any infrastructure to support quality improvement (QI) (Tucker and Edmondson, 2003). Also, in fee-for-service medicine, there are few financial incentives for health care organizations to invest in a quality management infrastructure. With poor performance on quality measures eating into provider revenue, health care leaders have a greater incentive, perhaps even a need, to create a quality management infrastructure. To improve safety, such an infrastructure should establish interdependence while allowing independence. Health care organizations need a structure that creates a chain of accountability to improve safety, defining accountable people at each level of the organization while encouraging innovation in how to improve. While safety and quality leaders have called for systems approaches to improve care, few organizations have the infrastructure to support such an approach. Hospitals and other health care organizations must provide an infrastructure that supports clinician-led efforts. They must also harness employees’ enthusiasm for patient safety, QI, and patient-centeredness to meet broader hospital-level (or even state- and national-level) initiatives by giving them the resources (equipment, evidence, and tools) and technical and motivational support needed to improve the system. The multi-level nature of the system requirements demands better coordination of available resources than typically done to date. Where can we look for solutions to the problem of Downloaded by JHU Libraries At 05:55 12 October 2016 (PT) coordination in multi-level systems? One place is biomimicry, which is the science of studying nature and applying its designs and processes to solve human problems. Nature has provided a model for addressing the quality management infrastructure problem, especially for complex and decentralized organizations – a fractal. Fractals, such as ferns, have self-similar patterns, wherein the whole object has the same shape as one or more of its parts, and all of the parts are connected to support and shape the larger structure in which it resides (Mandelbrot, 2012). For instance, the larger fern frond is composed of identically shaped fern leaves. Health care could accelerate improvements in safety with a quality infrastructure with such repeating patterns. We propose using a fractal organizational structure to inspire, implement, evaluate, and disseminate QI. The fractal approach is a repeating structure for building and supporting QI expertise, goal alignment, and communication
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