Sustaining reliability on accountability measures at The Johns Hopkins Hospital

Peter J. Pronovost, Christine G. Holzmueller, Tiffany Callender, Renee Demski, Laura Winner, Richard Day, J. Matthew Austin, Sean M. Berenholtz, Marlene R. Miller

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: In 2012 Johns Hopkins Medicine leaders challenged their health system to reliably deliver best practice care linked to nationally vetted core measures and achieve The Joint Commission Top Performer on Key Quality Measures® program recognition and the Delmarva Foundation award. Thus, the Armstrong Institute for Patient Safety and Quality implemented an initiative to ensure that ≥ 96% of patients received care linked to measures. Nine low-performing process measures were targeted for improvement - eight Joint Commission accountability measures and one Delmarva Foundation core measure. In the initial evaluation at The Johns Hopkins Hospital, all accountability measures for the Top Performer program reached the required ≥ 95% performance, gaining them recognition by The Joint Commission in 2013. Efforts were made to sustain performance of accountability measures at The Johns Hopkins Hospital. Methods: Improvements were sustained through 2014 using the following conceptual framework: declare and communicate goals, create an enabling infrastructure, engage clinicians and connect them in peer learning communities, report transparently, and create accountability systems. One part of the accountability system was for teams to create a sustainability plan, which they presented to senior leaders. To support sustained improvements, Armstrong Institute leaders added a project management office for all externally reported quality measures and concurrent reviewers to audit performance on care processes for certain measure sets. Conclusions: The Johns Hopkins Hospital sustained performance on all accountability measures, and now more than 96% of patients receive recommended care consistent with nationally vetted quality measures. The initiative methods enabled the transition of quality improvement from an isolated project to a way of leading an organization.

Original languageEnglish (US)
Pages (from-to)51-60
Number of pages10
JournalJoint Commission Journal on Quality and Patient Safety
Issue number2
StatePublished - Feb 2016

ASJC Scopus subject areas

  • Leadership and Management


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