Figure 1.

model for organisation-wide dissemination: interactions between plan-do-study-act cycles at the unit and hospital levels. The strategy for diffusion and sustainability begins with the implementation of projects in a few pilot units (left cycle). As soon as the hospital management (right cycle) notices that targets are realised or substantial improvement has occurred, these results are used as a baseline for other units. The new norm is added to the yearly policy documents that mark the start of the planning and control cycle. Within this framework, performance agreements are made with unit heads under the assumption that this will stimulate adoption of first-year lessons in an attempt to obtain similar results (again the left cycle). Both cycles are linked to each other. Units receive the means required for implementation (support), and on average, they report their progress to the management four times a year (accountability).