Unnecessary patient harm occurs in all health systems, adding to health expenditure and raising political pressure for public accountability and improved governance. In pediatric cardiac surgery, harm can manifest in child suffering and morbidity, the need for additional care, longer-term disability and even death.

Pediatric cardiac services planning mandates balancing the benefits of local access to  surgery with the perceived benefits of larger case volume on system reliability and patient outcomes. Yet pediatric cardiac surgery across the globe did not develop in alignment with such planning
principles.

The literature from the current era favors sites with large case volume often mandating large travel distances, imposing significant burdens on parents and potentially disrupting local and regional networks and care pathways. Provision of pediatric cardiac surgery is also driven by market forces and demographic changes.

Clinical microsystems consisting of talented individuals may provide broadly equivalent and reliable outcomes to those of large centers in
selected patients at smaller sites.