Central versus Local Quality Efforts: The Need for Both

Healthcare is in need of improvement. It harms too often, costs too much, learns and improves too slowly, and burns out its workforce. Large healthcare systems (HCS) have an important role in influencing the quality and value of care. Still, as systems that, in most cases, have grown and emerged rapidly in the last 20 years, few have organizational structures to support and foster the last aim, creating the conditions for the healthcare workforce to find joy and meaning in their work. HCS struggle to develop quality improvement (QI) because they are diverse and dynamic in composition, size, resources, culture and social structures, and needs. This diversity may drive forces for change or may undermine QI efforts. Clinical teams often rely on local QI efforts to improve care at the delivery site. At the same time, managers and executives focus on a centralized, system-wide approach, generally focused on externally reported metrics. We propose that a hybrid of the 2 most popular healthcare QI approaches, local QI and centralized QI, might be the best method for achieving and sustaining quality care across a wide variety of conditions.