Abstract
Health system executives continually aim to understand how organizational structures impact performance, especially in quality departments. This article, built on over 2 decades of Vizient research, identifies key characteristics of top-performing healthcare organizations. The researchers employed a modified Delphi methodology, involving a multiphase process that integrated literature reviews, content analyses, and expert consensus from top-performing organizations. Key findings reveal that top-performing organizations employ centralized goal setting with decentralized responsibility for implementation, fostering shared accountability at all levels. Horizontal integration underscores the multidisciplinary nature of top-performing quality departments, integrating diverse functions such as patient safety, infection control, and data analytics. Adaptability is an essential factor, with organizations incorporating evolving functions like ambulatory care and analytics, reflecting the dynamic needs of health care systems. By embracing adaptable, integrative, and balanced frameworks, organizations can position themselves to respond effectively to emerging challenges, maintain operational efficiency, and uphold high standards of care delivery.
Keywords: health care quality, top-performing organizations, quality structures, organizational excellence, health care leadership, operational efficiency
Introduction
Health system executives continually seek to understand the relationship between organizational structure and performance, turning to Vizient to provide best-in-class examples of organizational structure. In response, Vizient aimed to build upon its 20 years of research on the characteristics of top-performing organizations to include the structure of quality departments within these organizations.
In 2005, Vizient initiated research focused on identifying the characteristics of top-performing organizations. During the first study, 5 key characteristics were found to be unique among top performing organizations, including a shared sense of purpose, a hands-on leadership style, a focus on results, defined accountability at all levels of the organization and interprofessional collaboration.1 In 2012, a preliminary survey of 75 Chief Quality Officer’s (CQO) focused on the major functions of the performance improvement department structure and responsibilities.2 It identified key functions that were included within the quality department, and highlighted the need for more information on organizational alignment and accountability structures.
The current study addresses gaps in previous research by laying out foundational concepts underlying successful quality structures. Additionally, it articulates the insights of those top-performing organizations on structure and how structure can be operationalized, taking into account the evolution of health care in general, and quality in health care in particular. The findings from this study can be used as a roadmap to help other healthcare organizations conceptualize the structure of their quality department and provide guidance on how to translate it into a high-performing operational model.
Methodology
The study began with a literature review to understand the current state and significance of structure within healthcare organizations’ quality departments. The results of this review provided rationale for a framework that was constructed to guide the content analysis of quality structures and discussions with top-performing organizations (Figure). The framework consisted of 4 themes that are believed to underline the successful structure of quality departments.
Figure.
Quality structure framework findings.
Top performing organizations were identified to participate through Vizient’s annual Quality and Accountability Study, in which organizations are assigned a score and ranked based on performance on 150 quality metrics of patient care in 6 domains: mortality, safety, effectiveness, efficiency, patient centeredness, and equity. The organizations identified through this method were subsequently convened in an exclusive cohort called top performers for large integrated delivery networks to distinguish the unique characteristics of these organizations.
These top-performing organizations excel across all domains, particularly in mortality and safety, which each account for 25% of the total Quality and Accountability score and demonstrate low complication and mortality rates, operational efficiency through reduced length of stay and direct costs, and high-quality patient experiences as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. They also show strong equity performance by minimizing disparities in outcomes and processes across gender, race, and socioeconomic status. Organizations that were invited to participate in the study exhibit balanced excellence across clinical outcomes, patient engagement, cost management, and equitable care delivery.3
A modified Delphi technique consisting of 3 rounds was used to engage these “Top Performers” in building consensus for organizing and operationalizing quality departments. The researchers selected the modified Delphi technique due to its structured, iterative nature, which is well-suited for achieving expert consensus through multiple rounds of feedback, particularly when addressing complex and multifaceted concepts.4
In the modified Delphi technique developed for this study, an adjustment was made to one of the key components of the traditional method: anonymity. Typically, anonymity is employed to encourage participants to express their opinions freely and independently, without the influence of others’ views. However, in this modified approach, the component of anonymity was removed. This alteration allows participants to be aware of each other’s identities and to hear the opinions and share feedback and evolve insights throughout the process.
In round 1, quality structures were requested from the top-performing organizations (n = 8 organizations) in September 2024. Structures were submitted by Froedtert ThedaCare Health, Memorial Hermann Health System, NYU Langone Health, UC San Diego Health, University of Utah Health, Cleveland Clinic, Intermountain Health, and Keck Medicine of USC. Content analysis methods were utilized to examine the quality structures to identify commonalities and to pinpoint unique functions across different organizations. Functions were tabulated based on their frequency of appearance in each structure. These findings were then compared with the 2012 Performance Improvement Resources Survey by Vizient, which identified common functions included under hospital quality departments. Functions were identified as shifting away from the quality department, continuing to reside within it, or being added since 2012. Notable for further exploration in Round 2 was the structural support to evaluate care across the continuum and the integrated role of data and analytics in the quality department.
In the second round of the study, 3 months later, a roundtable discussion was convened at the Vizient annual Summit, where the findings from the literature review and content analysis were presented to the top performers (n = 8 organizations). Participants from the top-performing organizations provided feedback on the constructed framework and debated which functions belong within the department. Data collected from this round were used to reconstruct the original framework and then to collapse and simplify the important structural components.
In the third round, 1 month later, the top-performing organizations confirmed their opinions by reviewing and validating their contributions in this culminating written document (n = 8 organizations). This step ensured that the insights and perspectives shared throughout the study were accurately represented, resulting in a robust and reliable final assessment.
Key Findings
Centralization/Decentralization
Of the 5 key characteristics of top-performing organizations outlined in 2005, the current study identified that commitment to accountability systems continues to be an important influence when structuring successful quality teams.1 Top performing organizations demonstrate their commitment to accountability to quality goals by implementing a mix of centralized control and decentralized responsibility. They develop and set quality goals in a centralized manner – and defer to local and unit-level leaders to determine the most appropriate tactics to improve performance on those goals (referred to as decentralized responsibility). An analysis of existing studies revealed that some organizations have successfully leveraged this understanding to shape their structures. For example, implementation of fractal-based infrastructure models that integrate centralized, system-wide leadership with subcommittees supported accountability at the hospital level.5 Mathews et al6 describe a more granular view of how the fractal model plays out at the department level, emphasizing the need for flexibility to address local priorities while still adhering to system-wide goals. In its 2021 white paper, the Institute for Healthcare Improvement underscored the value of combining centralized oversight with decentralized action, offering examples of other successful healthcare organizations that have adopted similar strategies in organizing their quality departments.7
Content analysis of the submitted organizational structures supported the conclusion that centralization of control and decentralization of accountability are key components underpinning the structure of top-performing quality departments. Even though each organization’s structures are different, common themes emerge. Overall, it is clear how the theme of centralization manifests in quality structures. System-wide quality leaders are depicted to have some version of a formalized reporting structure or dotted line to local entities. Yet, it is unclear how to decipher decentralized responsibility within a visual organizational structure. During the first round, the researchers assumed that the documented reporting structures allowed local leadership in the organizations to have some connection to the system level, allowing shared accountability throughout the department. This was not entirely clear through organizational structure analysis. Additional context is needed.
This theme of shared accountability – where ownership of quality goals is shared across the department from local team members to central leadership – is believed to be how the ideas of centralization and decentralization are operationalized. Roles in the department are accounted for and mapped out in a structure underneath central leadership. These roles then act as bridges that cascade goals down to the local level, creating a level of transparency that is critical to hold individuals at every level accountable. It is this accountability that leads to local leaders initiating grassroots-level initiatives to improve.
Insights From Top-Performing Organizations
Top-performing organizations may differ in the degree of centralization of their quality and safety efforts, yet a unifying principle binds them: the presence of shared goals that are centrally monitored. Most top performers agree that centralization enhances efficiency through economies of scale, with some demonstrating both cost savings and improved performance.
The commonalities of people are, first and foremost, leadership commitment, especially at the level of the board. This commitment to high-quality care and intolerance to patient harm then permeates through all levels of the organization. The commitment from the board level to learn from preventable harm events and deploy action plans throughout the health care system is pertinent. The top performers for large integrated delivery networks acknowledged that while most board members are non-health care members, many come from industries where quality and safety are also paramount. The challenge is then pivoted to educating the board of the particulars of health care quality and safety that may be similar but unique from other industries. A rotation of board members in serving on the quality committee of the board is 1 effective way to ensure all board members are well versed in health care quality terms and knowledge. Having the Chief Executive Officer support is paramount for quality to be at the forefront and the foundation of the health care system. It is important to ensure that quality is not just an agenda item but the bedrock of the organizational mission.
Continuous quality education is needed not only at the level of the board, but also all through the organization, from the C-suite to teams. The Vizient top performers network exemplifies the importance of ensuring key quality leaders remain current in their fields while actively elevating quality standards—not just within their institutions, but also on state, national, and international platforms. Top performing organizations are typically seeking opportunities for their key leaders to be connected, participate in collaboratives, and to be continuously educated as health care evolves.
Culturally, these top performing organizations thrive by striking a delicate balance between shared accountability and psychological safety—2 principles they see as inseparable. Accountability is not limited to leaders alone but extends across the organization, with front-line teams contributing through well-designed process measures that are grounded in evidence and aimed at achieving shared outcome goals. This cultural ethos encourages both responsibility and collaboration, creating an environment where successes are celebrated and failures are seen as opportunities to learn and grow. Shared accountability, however, is only possible in a culture of psychological safety, where individuals feel secure in voicing concerns, sharing experiences, and innovating without fear of blame. These insights are in line with findings from Vizient’s earlier Systemness Benchmarking Study conducted in 2019 that concluded cohesive culture and strong executive alignment are essential for driving meaningful integration and performance improvement across health systems.8
Horizontal Integration
Horizontal integration and adaptability are essential components of successful quality department structures in healthcare organizations. By integrating diverse functions across quality teams and ensuring that these structures are flexible and adaptable to changing needs, health care systems can improve care delivery, enhance patient outcomes, and remain at the forefront of quality improvement (QI). Based on the content analysis of the submitted organizational structures, horizontal function integration is identified as a major domain that underlies the structure of quality departments.
Horizontal integration refers to the breadth and depth of multidisciplinary functions and teams within the quality department. This approach brings together professionals from diverse disciplines and areas of expertise, integrating functions within the quality department to foster a comprehensive and coordinated approach to QI. For instance, a quality structure that incorporates professionals from various fields, such as patient safety, infection control, risk management, and clinical process improvement, exemplifies horizontal integration. This structure ensures that all aspects of quality are addressed cohesively, leading to more effective and efficient outcomes.
An analysis of the quality structures of top performers (Table) revealed the following prevalence of functions compared to the Vizient 2012 PI resources survey findings: Currently patient safety and infection control/antimicrobial stewardship functions are present in 88% of the structures, risk management in 75%, clinical process improvement and accreditation/regulatory compliance each in 63%, patient satisfaction, operational process improvement, and clinical documentation improvement each in 25%, and case management/utilization management in 13% (Table). Credentialing and peer review were not found in any of the structures.8 Conversely, in 2012, more quality structures included credentialing and case management/utilization management.
Table.
Content Analysis of Organizational Structures of Top Performing (as Determined by Vizient’s Quality and Accountability Study) Healthcare Organizations’ Quality Departments (n = 8) Revealed the Prevalence of Certain Functions Within Those Departments.
| Functions | Number of structures with identified function | Percentage of structure with identified function |
|---|---|---|
| Patient safety | 7 | 88% |
| Infection control/antimicrobial | 7 | 88% |
| Analytics | 6 | 75% |
| Risk management | 5 | 63% |
| Clinical process improvement | 5 | 63% |
| Accreditation/regulatory compliance | 5 | 63% |
| Ambulatory | 5 | 63% |
| Patient satisfaction | 2 | 25% |
| Operational process improvement | 2 | 25% |
| Clinical documentation improvement | 2 | 25% |
| Case management/utilization management | 1 | 13% |
| Credentialing and peer review | 0 | 0% |
Credentialing and Peer Review were included in this table, as this data was compared to previous findings from a 2012 Vizient Survey, which found this function to be previously included in the quality departments of certain organizations.
The concept of adaptability is central to the operationalization of horizontal functional integration, enabling organizations to respond effectively to emerging challenges and opportunities. In the context of quality structures, adaptability refers to the capacity of health care systems to adjust and evolve in response to shifting market demands and innovations. This agility is essential for maintaining the relevance and effectiveness of quality initiatives in a rapidly changing health care environment. As health care systems evolve and grow through merger and acquisition activity, leaders must be agile to the practices/perspectives that new hospitals bring. A prime example of this adaptability is the integration of new functions, such as data analytics and ambulatory care, into the quality structure. These strategic additions not only reflect the changing landscape of health care needs but also align with the evolving priorities of organizations striving to improve care delivery and outcomes.
From the analysis of top performers’ quality structures, it was found that in 2024, analytics was present in 88% of the structures, and ambulatory care was present in 63% (Table). In the 2012, these components were not present in quality structures as they are today. This highlights the importance of adapting functions as new needs emerge to lead QI. Adaptability is vital for quality structures as it allows organizations to respond to new challenges and opportunities. By incorporating new functions like analytics and ambulatory care, healthcare organizations can leverage data-driven insights and improve care delivery in outpatient settings and across the continuum of care.
Adaptability also involves shifting the focus of responsibility, which can significantly improve quality structures by streamlining functions and ensuring that each department is optimally utilized. This shift often involves reallocating certain functions that were traditionally under the quality department to other departments where they can be more effectively managed. A prime example is the decline of case management/utilization management and credentialing and peer review within the quality structure. This shift allows the quality department to focus more on core QI activities, while other departments handle functions that are more aligned with their expertise.
Insights From Top-Performing Organizations
In examining the practices of top-performing healthcare organizations, several key takeaways emerged regarding horizontal functional integration and adaptability. A primary focus is intentionality in alignment and avoiding redundancy, as caregivers often experience frustration when similar messages are delivered repeatedly by multiple departments, leading to confusion and inefficiency. Breaking down departmental silos and aligning functions across the organization is another critical opportunity, fostering collaboration and driving efficiency in QI efforts. Top performers have centralized quality and safety structures, where central teams are accountable for local goals while providing on-the-ground support. This centralization aligns efforts with organizational priorities and reduces duplicative functions, further supporting the pursuit of clinical excellence. Achieving this alignment involves reviewing medical literature, analyzing Vizient data, and engaging with front-line teams to drive continuous improvement. Additionally, mechanisms for workforce integration across brick-and-mortar facilities and shared services or institutes are essential to ensure effective collaboration between centralized and local quality and clinical leaders. By addressing these aspects, organizations can improve patient care and operational efficiency through a unified and intentional approach.
Top-performing healthcare organizations also emphasize adaptability as a critical component of QI, with several key strategies emerging. Many are integrating ambulatory care into their quality structures, reflecting a shift toward holistic approaches that extend beyond hospital settings. A leading example of centralized adaptability is a health system operating across multiple states that has integrated safety, quality, infection control, and risk management at the system level, rather than reporting directly to local entities. Additionally, successful organizations balance centralization and decentralization, ensuring local teams have the autonomy and resources to address specific needs while benefiting from system-wide standardization and shared learning. These insights highlight the ongoing evolution of quality structures, emphasizing alignment, efficiency, shared goals, and a strategic approach to clinical and operational quality management.
Discussion
The classic Donabedian model, which posits that structure and process lead to outcomes, underscores the critical role of organizational structure in driving QI initiatives.9 In this framework, structure—captured in organizational charts—serves as a foundation that defines key components such as reporting relationships, roles, responsibilities, and accountability. It aligns an organization’s resources and efforts with its broader goals, ensuring a coordinated approach to achieving quality outcomes.
The present study was undertaken to assess the organizational structures of top-performing health care systems. The focus was to identify commonalities across these organizations and evaluate changes in their QI structures since a similar study was conducted in 2012. The assessment was guided by a group of executive quality leaders from large health care systems, each bringing decades of experience and a combined total of approximately 100 years in health care leadership. While there are evidence-based frameworks for designing quality department structures, evaluating team interactions as depicted on paper proved challenging. The discussion among the leaders of high-performing systems elucidated that culture and communication were critical to success in driving towards clinical excellence, but these factors are difficult to describe in an organizational chart. Most organizational structures lacked detailed definitions of functional roles, making it difficult to assess how teams collaborate effectively in practice.
As an important insight, 1 must suggest that health care systems are evolving to serve their communities, and as medicine evolves, quality in health care evolves as well. As such, the structure of the quality department in any health care system may be dynamic. The principles of delivering highly reliable care, and the clarity of roles, responsibilities and accountabilities across the systems must be respected, but the structure itself might vary between systems or even longitudinally across a single health care system.
This highlights an important opportunity for further collaboration and the sharing of more detailed structural and functional information. The structure in and of itself is vital to detail the roles, responsibilities, and connections so that team members have a roadmap and operating model. By doing so, organizations can better understand how to optimize their structures to support continuous improvement in quality and safety, ensuring they remain high-performing in these critical areas. Connections between the system structures and the individual hospital structures must be defined to direct and guide team accountability, interactions, and partnership.
Beyond the significance of building the right structure and infrastructure for quality departments of the future, most top performers agree that the culture of an organization, which includes the relentless commitment to high-quality of care, plays a significant role in patient outcomes. Culture depends primarily on the capability and effectiveness of key leaders within the organization, including board members, the CQO, the Chief Nursing Officer, the Chief Medical Officer, and the CQO. All these key players may benefit from continuous education and from being connected to professional networks, nationally and within their own organization. The structure should support the work and the culture.
Limitations
This study adds to the body of knowledge about the characteristics of top-performing organizations and the relevance of structure to support outcomes. It is important to acknowledge that the organizations identified and included in this analysis predominantly comprise large, integrated health systems. As such, the insights and conclusions drawn may not be readily generalizable to smaller, independent hospitals or group practices.
Additionally, the study does not fully explore the potential influence of external policy and macro-environmental forces that have significantly shaped health care quality structures over the last decade. Since 2012, the implementation of major value-based programs under the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act has driven systemic shifts in quality measurement, accountability, and care delivery.10 These federal initiatives incentivized performance-based outcomes and required health systems to adapt accordingly. These factors may have contributed to changes in departmental structures and priorities, but they were not explicitly examined in this study.
Furthermore, the global COVID-19 pandemic represents a profound inflection point in health care delivery and quality oversight.11 Although many of the organizational structures analyzed were submitted in the postpandemic context, the study does not discuss how the pandemic may have influenced these structures.
As external policies and macro-level disruptions continue to shape the health care landscape, quality department structures will likely need to evolve in parallel to remain effective, responsive, and aligned with emerging priorities.
Conclusion
This comprehensive evaluation of the organizational structures across top-performing organizations in Vizient’s Quality & Accountability Top Performers demonstrated a changing landscape in health care quality, with structures including less credentialing and utilization management and more ambulatory and analytic functions since 2012.
Moreover, the study emphasizes the critical balance between centralization and decentralization as a driving force for achieving shared accountability and operational flexibility. While centralization is evident in organizational structures, decentralization is less explicitly depicted in the organization’s structure and is instead represented through the perspectives of top performers. The study also highlights that organizational charts themselves are often lacking in detail and would benefit from a clearer depiction of the operational roadmap. Such enhancements could improve organizational alignment by clearly delineating responsibilities and fostering a better understanding of who is accountable for what. By fostering a culture of collaboration and integrating diverse functions horizontally within quality departments, organizations can enhance their adaptability to meet the evolving demands of the health care landscape. The emphasis on psychological safety and continuous education among leaders further underscores the importance of cultivating a supportive environment where innovation and accountability coexist harmoniously.
Horizontal integration and adaptability remain key components in optimizing quality department structures. Incorporating functions such as data analytics and ambulatory care highlights the need for a forward-thinking approach that aligns with emerging health care priorities. This evolution not only supports improved patient outcomes but also ensures that organizations are equipped to navigate complex, dynamic systems effectively.
While this study provides a roadmap for refining quality department structures, it also highlights the need for a broader understanding of how cultural and governance factors impact quality performance. It also highlights the important role of leadership to utilize the organizational structure to guide responsibility, accountability, and filling in the gaps needed in the white space that is not explicitly outlined. In the organizational structure. By prioritizing ongoing research into these areas, health care systems can further optimize their organizational frameworks, respond effectively to dynamic challenges, and uphold the highest standards of care.
Ultimately, the findings affirm that structural frameworks provide a critical foundation for QI. A relentless commitment to high-quality care, supported by visionary leadership and robust frameworks, is the cornerstone of any high-performing healthcare organization. By embracing the principles outlined in this study, health care systems can position themselves to achieve excellence in quality, patient safety, and overall care delivery.
Conflicts of Interest
Chang, Graves, Ikezuagu, Lu, Miller, and Schaal have no conflicts of interest to disclose. Cerese, Levine, Grubeling, Sauls, and Siddiqui are employed by Vizient.
Funding
All phases of this study were supported by Vizient. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Author Contributions
Dr Chang contributed significantly to the Centralization/Decentralization section. Dr Graves contributed to the Horizontal Functions Integration section and conclusion. Dr Ikezuagu and Dr Schaal contributed to the Centralization/Decentralization section. Dr Lu contributed significantly to the Horizontal Functions Integration section. Dr Miller contributed to the Centralization/Decentralization and Horizontal Functional Integration section. Cleveland Clinic, Froedtert & ThedaCare Health, Intermountain Healthcare, Keck Medicine of the University of Southern California, Memorial Hermann Health System, NYU Langone Health, UC San Diego Health, and University of Utah Health provided their quality structures for our qualitative analysis. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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