title: Establishing an Ambulatory Medicine Quality and Safety Oversight Structure: Leveraging the Fractal Model.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: S.J. Kravet is president, Johns Hopkins Community Physicians, vice president, Office of Johns Hopkins Physicians, chief quality officer for ambulatory practice, Johns Hopkins Medicine, and associate professor of medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. J. Bailey is senior director of quality and transformation, Johns Hopkins Community Physicians, Office of Johns Hopkins Physicians and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. R. Demski is vice president of quality, Johns Hopkins Health System and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. P. Pronovost is senior vice president for patient safety and quality and director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and professor of anesthesiology and critical care medicine, surgery, and health policy and management, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kravet
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bailey
authors.forename: Renee
authors.initials: R
authors.lastname: Demski
authors.forename: Peter
authors.initials: P
authors.lastname: Pronovost
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration / Q000592:standards*; D000553:Ambulatory Care / Q000458:organization & administration / Q000592:standards*; D017709:Fractals; D006801:Humans; D008396:Maryland; D017146:Models, Organizational; D061214:Patient Safety / Q000592:standards*; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards*