Demonstrating high reliability on accountability measures at the johns hopkins hospital

Peter J Pronovost, Renee Demski, Tiffany Callender, Laura Winner, Marlene R. Miller, Matthew J. Austin, Sean M. Berenholtz

Research output: Contribution to journalArticlepeer-review


Background: Patients continue to suffer preventable harm from the omission of evidence-based therapies. To remedy this, The Joint Commission developed core measures for therapies with strong evidence and, through the Top Performer on Key Quality Measures® program, recognize hospitals that deliver those therapies to 95% of patients. The Johns Hopkins Medicine board of trustees committed to high reliability and to providing ≥ 96% of patients with the recommended therapies. Methods: The Armstrong Institute for Patient Safety and Quality coordinated the core measures initiative, which targeted nine process measures for the 96% performance goal: eight Joint Commission accountability measures and one Delmarva Foundation core measure. A conceptual model for this initiative included communicating goals, building capacity with Lean Sigma methods, transparently reporting performance and establishing an accountability plan, and developing a sustainability plan. Clinicians and quality improvement staff formed one team for each targeted process measure, and Armstrong Institute staff supported the teams- work. The primary performance measure was the percentage of patients who received the recommended process of care, as defined by the specifications for each of The Joint Commission-s accountability measures. Results: The ≥ 96% performance goal was achieved for 82% of the measures in 2011 and 95% of the measures in 2012. Conclusions: With support from leadership and a conceptual model to communicate goals, use robust improvement methods, and ensure accountability, The Johns Hopkins Hospital achieved high reliability for The Joint Commission accountability measures.

Original languageEnglish (US)
Pages (from-to)531-544
Number of pages14
JournalJoint Commission Journal on Quality and Patient Safety
Issue number12
StatePublished - Dec 2013
Externally publishedYes

ASJC Scopus subject areas

  • Leadership and Management


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