Problem Academic health systems face challenges in the governance and oversight of quality and safety efforts across their organizations. Ambulatory practices, which are growing in number, size, and complexity, face particular challenges in these areas. Approach In February 2014, leaders at Johns Hopkins Medicine (JHM) implemented a governance, oversight, and accountability structure for quality and safety efforts across JHM ambulatory practices. This model was based on the fractal approach, which balances independence and interdependence and provides horizontal and vertical support. It set expectations of accountability at all levels from the Board of Trustees to frontline staff and featured a cascading structure that reached all units and ambulatory practices. This model leveraged an Ambulatory Quality Council led by a physician and nurse dyad to provide the infrastructure to share best practices, continuously improve, and define accountable local leaders. Outcomes This model was incorporated into the quality and safety infrastructure across JHM. Improved outcomes in the domains of patient safety/risk reduction, externally reported quality measures, patient care/experience, and value have been demonstrated. An additional benefit was an improvement in Medicaid value-based purchasing metrics, which are linked to several million dollars of revenue. Next Steps As this model matures, it will serve as a mechanism to align quality standards and programs across regional, national, and international partners and to provide a clear quality structure as new practices join the health system. Future efforts will link this model to JHM's academic mission, enhancing education to address Accreditation Council for Graduate Medical Education core competencies.
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