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Current models guiding improvement tend to undervalue the tensional nature of hospitals. Applying a dualities approach that is sensitive to tensions inherent to hospitals\u2019 quest for improved quality, this article aims to identify which organizational dualities managers should particularly pay attention to.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A set of cross-national, multi-level case studies was conducted involving 383 semi-structured interviews and 803\u2009h of non-participant observation of key meetings and shadowing of staff in ten purposively sampled hospitals in five European countries (England, the Netherlands, Portugal, Sweden, and Norway).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Six dualities that describe the quest for improved quality, each embracing a seemingly contradictory feature were identified: plural consensus, distributed connectedness, orchestrated emergence, formalized fluidity, patient coreness, and cautious generativeness.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>We advocate for a move from the usual sequential and project-based and systemic thinking about quality improvement to the development of meta-capabilities to balance the simultaneous operation of opposing ideas or concepts. Doing so will help hospital managers to deal with major challenges of change inherent to quality improvement initiatives.<\/jats:p><\/jats:sec>","DOI":"10.1186\/s12913-020-05488-9","type":"journal-article","created":{"date-parts":[[2020,7,16]],"date-time":"2020-07-16T09:02:46Z","timestamp":1594890166000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Enacting quality improvement in ten European hospitals: a dualities approach"],"prefix":"10.1186","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5848-6451","authenticated-orcid":false,"given":"Francisco G.","family":"Nunes","sequence":"first","affiliation":[]},{"given":"Glenn","family":"Robert","sequence":"additional","affiliation":[]},{"given":"Anne Marie","family":"Weggelaar-Jansen","sequence":"additional","affiliation":[]},{"given":"Siri","family":"Wiig","sequence":"additional","affiliation":[]},{"given":"Karina","family":"Aase","sequence":"additional","affiliation":[]},{"given":"Anette","family":"Karltun","sequence":"additional","affiliation":[]},{"given":"Naomi J.","family":"Fulop","sequence":"additional","affiliation":[]}],"member":"297","published-online":{"date-parts":[[2020,7,16]]},"reference":[{"issue":"5","key":"5488_CR1","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1177\/1077558708318285","volume":"65","author":"A Cohen","year":"2008","unstructured":"Cohen A, Restuccia J, Shwartz M, Drake J, Kang R, Kralovec P, Holmes S, Margolin F, Bohr D. 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