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The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety.

Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes.

The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model.

This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors’ knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.

The purpose of this study is to demonstrate how action learning can be practically applied to quality and safety challenges at a large academic medical health system and become fundamentally integrated with an institution’s broader approach to quality and safety.

The authors describe how the fundamental principles of action learning have been applied to advancing quality and safety in health care at a large academic medical institution. The authors provide an academic contextualization of action learning in health care and then transition to how this concept can be practically applied to quality and safety by providing detailing examples at the unit, cross-functional and executive levels.

The authors describe three unique approaches to applying action learning in the comprehensive unit-based safety program, clinical communities and the quality management infrastructure. These examples, individually, provide discrete ways to integrate action learning in the advancement of quality and safety. However, more importantly when combined, they represent how action learning can form the basis of a learning health system around quality and safety.

This study represents the broadest description of action learning applied to the quality and safety literature in health care and provides detailed examples of its use in a real-world context.

The US federal government requires auditors to follow governmental auditing standards when performing audits of entities expending significant federal government dollars. This study explores stakeholder participation during the comment letter phase of government auditing standard setting to determine if participation is symbolic or substantive.

Researchers conduct an analysis of the 179 comment letters submitted to the US Government Accountability Office (GAO) and received for their 2010 and 2017 exposure drafts of government auditing standards.

The distribution of stakeholder participation groups in the government auditing standard-setting process differs from the distribution in the private company auditing standard-setting process. On average, participants submit letters that are greater than two pages in length. Participants also contribute feedback on topics that the GAO directly solicits. Taken together, the results demonstrate stakeholder behaviors that are consistent with a substantive rather than symbolic due process involvement for government auditing standards.

Stakeholder beliefs are inferred based on the observed behavior of comment letter submissions. Also, there is a subjective element to the classification of the comment letters for the study.

Given the far-reaching implications of Yellow Book auditing standards on public, private and nonprofit entities, the findings are relevant to a heterogeneous audience. This study reveals opportunities for users of government auditing standards, practitioners and academics for greater involvement in due process standard setting to bring additional legitimacy to the GAO and its standard-setting activities.

Beyond the current study, little empirical research examines Yellow Book auditing standards or the due process through which these standards are established. This is the first study to examine the complete set of comment letters for the 2010 and 2017 exposure drafts of government auditing standards.