Front-line ownership (FLO) is a complexity science-based approach to leading change initiatives that is built upon a foundation of Positive Deviance and the use of Liberating Structures to engage others. In this paper, we outline the use of FLO in four successful patient safety or quality improvement projects in four countries. While the underlying principles guiding the use of FLO were the same for each of these projects, project goals, the types of roles involved and how the projects evolved, spread and were sustained, varied considerably between settings. Allowing for local variability while following consistent overarching simple rules is central to the FLO approach and we believe the key reason why it has met with success. While many parts of healthcare delivery require increased standardization, approaches that allow teams to develop implementation strategies based on their unique local situations, will likely meet with greater success than those that attempt to standardize implementation in addition to practice.