title: Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.
abstract: In this article, the authors describe an initiative that established an infrastructure to manage quality and safety efforts throughout a complex health care system and that improved performance on core measures for acute myocardial infarction, heart failure, pneumonia, surgical care, and children's asthma. The Johns Hopkins Medicine Board of Trustees created a governance structure to establish health care system-wide oversight and hospital accountability for quality and safety efforts throughout Johns Hopkins Medicine. The Armstrong Institute for Patient Safety and Quality was formed; institute leaders used a conceptual model nested in a fractal infrastructure to implement this initiative to improve performance at two academic medical centers and three community hospitals, starting in March 2012. The initiative aimed to achieve ≥ 96% compliance on seven inpatient process-of-care core measures and meet the requirements for the Delmarva Foundation and Joint Commission awards. The primary outcome measure was the percentage of patients at each hospital who received the recommended process of care. The authors compared health system and hospital performance before (2011) and after (2012, 2013) the initiative. The health system achieved ≥ 96% compliance on six of the seven targeted measures by 2013. Of the five hospitals, four received the Delmarva Foundation award and two received The Joint Commission award in 2013. The authors argue that, to improve quality and safety, health care systems should establish a system-wide governance structure and accountability process. They also should define and communicate goals and measures and build an infrastructure to support peer learning.
authors.affiliation: Dr. Pronovost is senior vice president of quality and safety, Johns Hopkins Medicine, director, Armstrong Institute for Patient Safety and Quality, and professor, Departments of Anesthesiology and Critical Care Medicine, Surgery, and Health Policy and Management, School of Nursing and Carey Business School, Johns Hopkins University, Baltimore, Maryland. Mr. Armstrong is chairman, Johns Hopkins Medicine Patient Safety and Quality Board Committee, and, until October 2013, was chairman, Johns Hopkins Medicine Board of Trustees, Baltimore, Maryland. Ms. Demski is vice president of quality improvement, Armstrong Institute for Patient Safety and Quality and Johns Hopkins Health System, Baltimore, Maryland. Ms. Callender is senior quality and innovation coach, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. Ms. Winner is director of Lean Sigma deployment, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. Dr. Miller is Johns Hopkins Medicine chief quality officer for pediatrics, vice chair of quality and safety, and professor, Department of Pediatrics, Johns Hopkins University, and core faculty, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. Dr. Austin is assistant professor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland. Dr. Berenholtz is professor, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, and Departments of Anesthesiology and Critical Care Medicine, Surgery, and School of Medicine, and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland. Dr. Yang is senior biostatistician, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland. 
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: C Michael
authors.initials: CM
authors.lastname: Armstrong
authors.forename: Renee
authors.initials: R
authors.lastname: Demski
authors.forename: Tiffany
authors.initials: T
authors.lastname: Callender
authors.forename: Laura
authors.initials: L
authors.lastname: Winner
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
authors.forename: J Matthew
authors.initials: JM
authors.lastname: Austin
authors.forename: Sean M
authors.initials: SM
authors.lastname: Berenholtz
authors.forename: Ting
authors.initials: T
authors.lastname: Yang
authors.forename: Ronald R
authors.initials: RR
authors.lastname: Peterson
authors.forename: Judy A
authors.initials: JA
authors.lastname: Reitz
authors.forename: Richard G
authors.initials: RG
authors.lastname: Bennett
authors.forename: Victor A
authors.initials: VA
authors.lastname: Broccolino
authors.forename: Richard O
authors.initials: RO
authors.lastname: Davis
authors.forename: Brian A
authors.initials: BA
authors.lastname: Gragnolati
authors.forename: Gene E
authors.initials: GE
authors.lastname: Green
authors.forename: Paul B
authors.initials: PB
authors.lastname: Rothman
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D001249:Asthma / Q000628:therapy; D002648:Child; D003695:Delivery of Health Care / Q000458:organization & administration*; D006333:Heart Failure / Q000628:therapy; D006760:Hospitalization; D006764:Hospitals, Community; D006801:Humans; D008396:Maryland; D009203:Myocardial Infarction / Q000628:therapy; D019990:Perioperative Care; D011014:Pneumonia / Q000628:therapy; D017064:Process Assessment, Health Care; D058996:Quality Improvement / Q000458:organization & administration*