This commentary highights the key arguments and contributions of institutional thoery, transaction cost economics (TCE) theory, high reliability theory, and organizational learning theory to understanding the development and evolution of Accountable Care Organizations (ACOs). Institutional theory and TCE theory primarily emphasize the external influences shaping ACOs while high reliability theory and organizational learning theory underscore the internal fctors influencing ACO perfromance. A framework based on Implementation Science is proposed to conside the multiple perspectives on ACOs and, in particular, their abiity to innovate to achieve desired cost, quality, and population health goals.