This might be a clumsy question so please bear with me. I have wondered for a long time whether the most common quality paradigm/framework we use in hospitals is unhelpful. If we take the national model of safety, clinical effectiveness and (good) patient experience, it only goes so far in helping people design care systems that balance the many dimensions (and trade-offs) of optimising quality. Other models include concepts such as equity, efficiency and some include sustainability. Could it be part of what leads to silos of priority setting leading to separate workstreams and resources for things like cost improvement, transformation, safety. What framework or frameworks would you use in an organisation such as a hospital to shape thinking and to underpin a joined-up approach to prioritising improvement and the allocation of resources? Are you aware of any that are doing this in a more joined-up way than most? And is this the right SIG for this question?