The approach to front-line ownership proposed by Gardam et al. (2017) consists of many elements integral to most approaches to quality improvement. The mix of these elements may need to be modified in circumstances that have the most impact on patient safety, where a higher level of standardization may be essential and a more directive approach may be needed. The inclusion of patients as partners in quality improvement means that staff do not exclusively own the solutions and power must be shared with others whose views may be quite different. When this lens is applied, the concepts proposed by Gardam et al. do not resonate as strongly and in some cases may appear to promote a provider-centred approach where the experience and wisdom of patients, family and community are undervalued. The need to ensure consistency in quality of care across large systems will also require a balance between local customization and system-wide thinking and delivery, where strategies build on the successes of local teams while enabling timely spread throughout other units and sites.