This chapter argues that the regulation of hospital processes is not sufficient to ensure the organisational innovation required to sustain the reflexivity needed for safe, patient-focused care. It draws on Hi-Res analysis to identify the specific organisational dimensions of clinical governance. The chapter identifies three principal high road arenas: knowledge as a resource for improvement and innovation; partnership and involvement; job design and multidisciplinary team-working. Organisational structures, technologies, practices and cultures either help or hinder organisational learning and improvement. The Hi-Res study identifies several cases where new approaches to work organisation have been introduced to overcome identified obstacles to learning and improvement, ranging from the introduction of semi-autonomous team-working to the physical integration of R&D and production functions. The nature of clinical work organisation remains largely neglected and considerable variations in practice exist even within individual hospital Trusts. The arenas of organisational learning and innovation offer the scope to shift clinical governance from emphasis on compliance to improvement and innovation.