The quality movement has made major strides in developing a discipline and methodology for improvement, mostly focused on the front line of healthcare delivery. The planning of the level above this—hospitals and other large systems that deliver health services does not have the same rigour or discipline. Yet, the results of poor design of a hospital or of processes linking parts of health care together can be just as serious for patients as an unsafe clinical procedure. The lack of methodology also matters because the need to redesign the way that health care is delivered is becoming much more urgent. There are growing pressures from changes in medicine, a shrinking workforce, and increasing demands made on health care. Small incremental changes will not be enough to deal with these pressures. Could we harness the innovation, discipline, ability to borrow from elsewhere, and willingness to challenge the status quo that has often typified the quality movement and the best of medicine? Can we scale up the methodology of quality improvement to help those planning parts of the wider healthcare system do it better? I suggest three ways that this might be …