As we've taken this journey together towards gaining a better working knowledge of quality improvement in patient safety, we hope that you have come to understand that we appear to be rapidly approaching a major change in the way we measure, report, and use information on quality and safety in healthcare. Most of us believe that in times of great change, well informed and effective leadership can play a pivotal role in whether or not change is constructive or destructive. Moreover, because healthcare is so widely distributed, highly personalized, emotional, and often it has high stakes. Leadership within any given healthcare encounter is spread among many different providers. At any given moment, a receptionist, an aide, a technician, a social worker, nurse, or physician may be in a sense leading a particular facet of healthcare, along with the patient and family. The delivery of healthcare requires ongoing participation among a very complex set of individuals, comprising the patients care team. A similar level of teamwork and participation is required for effective safety and quality improvement work as well. That's virtually everyone engaged in direct patient care or quality improvement must at some point lead, and at other times be a skillful follower. In addition, given the evidence that we are at a crossroads in improving care, it's important to highlight the major tasks and characteristics required of leaders at all levels to bring about needed change to continue this forward progress in quality and safety. Effective leadership is not easy, and especially is difficult in times of crisis and change. What does it take to be an effective leader? It takes continually scanning the environment, being thoughtful, as well as supportive, and creating trust in those who work with you. Perhaps most importantly leading by example. It takes being in touch with your own feelings, living with in benevolence, being able to step out, and look at yourself critically. And being willing to change your own behaviors and beliefs. It's important to recognize that leading and fostering safety and quality improvement within an organization depends not just on the CEO, but, as we have noted in a number of times at all levels. Ultimately, leadership at any level of health care requires a deep and ongoing commitment to instilling higher quality and greater safety into the most careful stewardship of resources, into everything that we do. The commitment it takes to be an effective leader is broad and deep. Internal motivation and dedication to fostering safety and equality is important but so too is the growing pressure from external sources. We are clearly entering a time when information on quality and safety is becoming much more widely disseminated. Patients can now find quality ratings of individual physicians, hospitals, hospital services, home care, and nursing homes. In addition, many professional organizations around the world have inculcated lifelong learning, quality and safety, essential tenants of being a professional. The essential conclusion from all this is that, most if not all future healthcare providers will need to be well versed in how to lead and participate in teams and activities, focused on quality and safety improvement work. Before moving on to an in depth look at some of the critical features and effective leadership in healthcare, we want to touch on the overarching concept that is the direct outgrowth of effective leadership in this area, namely creating and maintaining a culture of quality. The culture of an organization is the set of values, core beliefs, attitudes, and actions that permeate the daily work of an organization. As an organization it has a culture of quality and safety, creates values, core beliefs, attitudes, and actions that are deeply grounded in fostering quality and safety at every level, in every process, and everyday. Implementing the PDSA cycle on a few projects or even having a director of quality with a large staff is not a contour of quality. A culture of quality means that an organization is open to change. A high quality organization is largely about change. About applying the PDSA process within an overall philosophy of quality, constantly figuring out how to do things better. Doing things better requires change. One way to describe then an organization that can adapt to change is a learning organization. Peter Senge defined learning organizations as organizations where people continually expand their capacity to create the results they truly desire and where new and expansive patterns of thinking are nurtured, where collective aspiration is set free and where people are continually learning to see the whole together. What kinds of people at all levels does it take to define and build a learning organization that embodies a culture of quality and safety? That is the essence of our focus for this module. We would again note that this module is not just for those who are in the executive suite. As we've repeatedly stressed, leadership is important at all levels of a learning organization that embraces a culture of quality and safety.