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The healthcare industry is on the journey toward high reliability. The industry works diligently to improve safety and quality, adopting some vitally important high reliability organization practices. While positive steps forward, these practices tend to be discrete initiatives to address specific challenges, and high reliability remains elusive. The journey taught us to view quality and safety not as a project, or even a portfolio of projects, but as an integrated operating management system. We are learning from industries that are further along on the high reliability organization journey, especially those compelled by widely publicized mishaps. These industries developed international consensus standards for integrated management systems to assure operational safety, quality, and reliability. Healthcare needs to evolve accordingly. Our work is informed by advanced systems engineering and mission assurance methodology, and research in high reliability organizing. The operating management system fosters two fundamental ways of working. First, it organizes processes and practices using a systems engineering approach to anticipate and reduce risks, mindfully standardizing work to prevent mishaps and improve performance. Second, it creates a culture of systems thinking and collaboration, building resiliency to recover from mishaps, when they occur, and promote mindful variation to deal effectively with unexpected situations. We share our motivation and approach to developing the operating management system, implementation examples and results achieved. While there is currently a large gap between idealized, highly reliable operations and current practice in healthcare, our experience demonstrates the benefits of this integrated systems management approach to address contemporary challenges and advance on the journey toward high reliability.

Purpose The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety. Design/methodology/approach Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes. Findings The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model. Originality/value This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors’ knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.

Background Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. Methods We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre– and post–patient blood management time periods. Results Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. Conclusions Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Purpose The purpose of this study is to demonstrate how action learning can be practically applied to quality and safety challenges at a large academic medical health system and become fundamentally integrated with an institution’s broader approach to quality and safety. Design/methodology/approach The authors describe how the fundamental principles of action learning have been applied to advancing quality and safety in health care at a large academic medical institution. The authors provide an academic contextualization of action learning in health care and then transition to how this concept can be practically applied to quality and safety by providing detailing examples at the unit, cross-functional and executive levels. Findings The authors describe three unique approaches to applying action learning in the comprehensive unit-based safety program, clinical communities and the quality management infrastructure. These examples, individually, provide discrete ways to integrate action learning in the advancement of quality and safety. However, more importantly when combined, they represent how action learning can form the basis of a learning health system around quality and safety. Originality/value This study represents the broadest description of action learning applied to the quality and safety literature in health care and provides detailed examples of its use in a real-world context.

As quality improvement and patient safety come to play a larger role in health care, academic medical centers and health systems are poised to take a leadership role in addressing these issues. Academic medical centers can leverage their large integrated footprint and have the ability to innovate in this field. However, a robust quality management infrastructure is needed to support these efforts. In this context, quality and safety are often described at the executive level and at the unit level. Yet, the role of individual departments, which are often the dominant functional unit within a hospital, in realizing health system quality and safety goals has not been addressed. Developing a departmental quality management infrastructure is challenging because departments are diverse in composition, size, resources, and needs.In this article, the authors describe the model of departmental quality management infrastructure that has been implemented at the Johns Hopkins Hospital. This model leverages the fractal approach, linking departments horizontally to support peer and organizational learning and connecting departments vertically to support accountability to the hospital, health system, and board of trustees. This model also provides both structure and flexibility to meet individual departmental needs, recognizing that independence and interdependence are needed for large academic medical centers. The authors describe the structure, function, and support system for this model as well as the practical and essential steps for its implementation. They also provide examples of its early success.

Background Large multihospital health systems with multiple children's hospitals are relatively few in number. With a paucity of national pediatric measures for quality and patient safety, there are unique challenges to ensuring consistent levels of care across diverse health care delivery settings. At Johns Hopkins Medicine, a Pediatric Joint Council was created to help ensure high-quality and safe care across a health system encompassing two full-service children's hospitals and two community hospitals with significant pediatric volumes across two states. Approach Across the health system, a governance, leadership, and management structure was developed to coordinate the quality and safety of patient care throughout the academic health system. Within the pediatric service line, the multidisciplinary Pediatric Joint Council included representation from each pediatric entity and was supported by project managers, quality improvement (QI) team leaders, QI leads from each entity, infection control, and clinical analysts. The Pediatric Joint Council was responsible for setting standards and improvement goals, as well as monitoring and improving performance of pediatric services across the health system and identifying training gaps and research opportunities. Conclusion The Pediatric Joint Council model, as implemented, provides a focused structure for coordinated efforts across disparate pediatric entities, ensuring horizontal peer learning and entity-specific improvements, as well as vertical lines of accountability and central oversight with shared governance. This model has served to help identify areas in need of pediatric expertise and has facilitated the use of resources from across the entire health system focused on improving pediatric care.

Background We hypothesized that integrating supply chain with clinical communities would allow for clinician-led supply cost reduction and improved value in an academic health system. Methods Three clinical communities (spine, joint, blood management) and one clinical community-like physician led team of surgeon stakeholders partnered with the supply chain team on specific supply cost initiatives. The teams reviewed their specific utilization and cost data, and the physicians led consensus-building conversations over a series of team meetings to agree to standard supply utilization. Results The spine and joint clinical communities each agreed upon a vendor capping model that led to cost savings of $3 million dollars and $1.5 million dollars respectively. The blood management decreased blood product utilization and achieved $1.2 million dollars savings. $5.6 million dollars in savings was achieved by a clinical community-like group of surgeon stakeholders through standardization of sutures and endomechanicals. Conclusions Physician led clinical teams empowered to lead change achieved substantial supply chain cost savings in an academic health system. The model of combining clinical communities with supply chain offers hope for an effective, practical, and scalable approach to improving value and engaging physicians in other academic health systems. Implications This clinician led model could benefit both private and academic health systems engaging in value optimization efforts. Level of evidence N/A

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations.Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs.Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies.The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

Coronavirus disease 2019 placed unprecedented challenges on the modern healthcare system. In addition to caring for patients directly affected by the virus, hospitals and clinics had to quickly mobilize forces in order to protect and manage employees with symptoms and/or exposures to COVID-19. Interventions are needed to efficiently diagnose and quarantine healthcare workers with disease while returning those without disease expediently in order to maintain a workforce capable of dealing with the pandemic surge. This article describes the Johns Hopkins system-wide occupational health response to the coronavirus outbreak. Specifically, the steps taken to develop and implement an employee covid call center that fielded 9,000 calls during the 2½ month initial surge of the virus are outlined. The 24/7 availability and rapid triage of healthcare workers led to an ultimate decline in call volume despite increasing exposure to the virus and rising hospitalizations.

Problem There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods. Approach We devised a dynamic framework, based on our 3-year experience using a Comprehensive Unit-Based Safety Program-a formal quality improvement committee structure, literature review, and work from The Johns Hopkins Armstrong Institute for Patient Safety and Quality. This framework is specific and exportable to the field of plastic surgery. Monthly patient safety, quality, and service committee meetings encourage multilevel participation in a bottom-up fashion, while connecting with other departments and entities in Johns Hopkins Medicine. Our model focuses our work in the following four domains: (1) safety, (2) external measures, (3) patient experience, and (4) value. Our framework identifies and communicates clear goals, creates necessary infrastructure, identifies opportunities and needs, uses robust performance to develop and implement interventions, and includes analytics to track improvement plans and results. Outcomes We have gradually implemented this quality improvement structure into the Johns Hopkins Department of Plastic and Reconstructive Surgery successfully since 2012. Outcomes have improved in externally reported measures of patient safety, quality, and service. We have demonstrated exemplary National Surgical Quality Improvement Program performance for morbidity, return to operating room, and readmission rates. Patient satisfaction surveys show improvement related to the high-level patient experience.

Article-at-a-Glance Background Enhanced recovery pathways (ERPs) for surgical patients may reduce variation in care and improve perioperative outcomes. Mainstays of ERPs are standardized perioperative pathways. At The Johns Hopkins Hospital (Baltimore), an integrated ERP was proposed to further reduce the surgical site infection rate and the longer-than-expected hospital length of stay in colorectal surgery patients. Methods To develop the technical components of the anesthesia pathway, evidence on enhanced recovery was reviewed and the limitations of the hospital infrastructure and policies were considered. The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function. ERP was implemented in phases during a 30-day period, starting with the anesthesiology elements and followed by the pre- and postoperative surgical team processes. The perioperative anesthetic regimen was tailored to meet the goal of preservation of perioperative immune function (in an attempt to decrease surgical site infection and cancer recurrence), in part by minimizing perioperative opioid use. Results After six months of exposure to all ERP elements, a 45% reduction in length of stay was observed among colorectal surgery patients. In addition, patient satisfaction scores for this cohort of patients improved from the 37th percentile preimplementation to > 97th percentile postimplementation. Conclusions Development of an ERP requires collaboration among surgeons, anesthesiologists, and nurses. Thoughtful, collaborative pathway development and implementation, with recognition of the strengths and weakness of the existing surgical health care delivery system, should lead to realization of early improvement in outcomes.

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.

Background As the health care system in the United States places greater emphasis on the public reporting of quality and safety data and its use to determine payment, provider organizations must implement structures that ensure discipline and rigor regarding these data. An academic health system, as part of a performance management system, applied four key components of a financial reporting structure to support the goal of top-to-bottom accountability for improving quality and safety. Four Key Components of a Financial Reporting Structure The four components implemented by Johns Hopkins Medicine were governance, accountability, reporting of consolidated quality performance statements, and auditing. Governance is provided by the health system's Patient Safety and Quality Board Committee, which reviews goals and strategy for patient safety and quality, reviews quarterly performance for each entity, and holds organizational leaders accountable for performance. An accountability plan includes escalating levels of review corresponding to the number of months an entity misses the defined performance target for a measure. A consolidated quality statement helps inform the Patient Safety and Quality Board Committee and leadership on key quality and safety issues. An audit evaluates the efficiency and effectiveness of processes for data collection, validation, and storage, as to ensure the accuracy and completeness of quality measure reporting. Conclusion If hospitals and health systems truly want to prioritize improvements in safety and quality, they will need to create a performance management system that ensures data validity and supports performance accountability. Without valid data, it is difficult to know whether a performance gap is due to data quality or clinical quality.

A national collaborative helped many hospitals dramatically reduce central line-associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units. Common practices led to 10 recommendations: executive and board leaders communicate the goal of zero CLABSI throughout the hospital; senior and unit-level leaders hold themselves accountable for CLABSI rates; unit physicians and nurse leaders own the problem; clinical leaders and infection preventionists build infection prevention training and simulation programs; infection preventionists participate in unit-based CLABSI reduction efforts; hospital managers make compliance with best practices easy; clinical leaders standardize the hospital's catheter insertion and maintenance practices and empower nurses to stop any potentially harmful acts; unit leaders and infection preventionists investigate CLABSIs to identify root causes; and unit nurses and staff audit catheter maintenance policies and practices.

BACKGROUND Although patient blood management (PBM) programs clearly reduce transfusion overuse, the relative impact on red blood cell (RBC), plasma, and platelet (PLT) utilization is unclear. STUDY DESIGN AND METHODS A retrospective analysis of electronic records was conducted at a medium-sized academic hospital to assess blood utilization for all inpatients admitted during 1-year periods before (n = 20,531) and after (n = 19,477) PBM efforts began in September 2014. Transfusion guideline compliance and overall utilization were assessed for RBCs, plasma, and PLTs. The primary PBM efforts included education on evidence-based transfusion guidelines, decision support in the computerized provider order entry system, and distribution of provider-specific reports showing comparison to peers for guideline compliance. Cost avoidance was determined by two methods (acquisition cost and activity-based cost), and clinical outcomes were compared during the two periods. RESULTS For RBCs, orders outside hospital guidelines decreased (from 23.9% to 17.1%, p < 0.001), and utilization decreased by 12% (p < 0.035). For plasma and PLTs, both orders outside guidelines and utilization changed minimally. Overall cost avoidance was $181,887/year by acquisition cost (and from $582,039 to $873,058/year by activity-based cost), 93% of which was attributed to reduction in RBC utilization. Length of stay, morbidity, and mortality were unchanged. CONCLUSIONS Our findings demonstrate a greater opportunity for reducing RBC compared to plasma and PLT utilization. A properly implemented PBM program has potential to reduce unnecessary transfusions and their associated risk and costs, without compromising clinical outcomes.

Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale.We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services.In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months--a 33.3% decrease (95% CI, 9-58%; p0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period.Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.

Article-at-a-Glance 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.

BACKGROUND: Improving surgical quality is a priority, but building a business case for the efforts could be challenging. Bridging the gap between the clinicians and hospital leaders is the first step to align quality and financial priorities within health care. OBJECTIVE: The aim of this study was to evaluate the financial impact of the surgical comprehensive unit-based safety program on colorectal surgery procedures. DESIGN: This a retrospective cohort study. SETTING: This study was conducted at a university-based tertiary care hospital. PATIENTS: All patients undergoing colectomy or proctectomy between July 2010 and June 2012 were included. INTERVENTION: A comprehensive unit-based safety program focused on colorectal surgical site infection reduction was implemented. Three surgeons participated in the program in year 1, and 5 surgeons participated in year 2. Patients were categorized as participating or nonparticipating based on the surgeon who performed the procedure. MAIN OUTCOME MEASURES: Resource utilization and cost were the main outcome measures. RESULTS: During the 2 years, there were 626 patients who met the selection criteria. Participating surgeons operated on 444 patients (70.9%), and the nonparticipating surgeons operated on 182 patients (29.1%). After adjusting for covariates, the variable direct cost was significantly lower for the participating surgeons in laboratory work by $191 (p = 0.009), operating room utilization by $149 (p = 0.05), and supplies by $615 (p = 0.003). The surgical site infection rates, need for an intensive care unit stay, and length of stay were not significantly different between the 2 groups. LIMITATIONS: The multiple biases related to surgeon self-selection for program participation and surgeon training and clinical skills were not addressed in this study owing to the limitations in sample size and data collection. CONCLUSION: A comprehensive unit-based safety program implementation, including dedicated frontline providers who focused on the standardization of protocols, was able to reduce the variation in resource utilization and costs in comparison with a control group.

Article-at-a-Glance Background Although the best allocation of resources is unknown, there is general agreement that improvements in safety require an organization-level safety culture, in which leadership humbly acknowledges safety shortcomings and allocates resources at the patient care and unit levels to identify and mitigate risks. Since 2001, the Johns Hopkins Hospital has increased its investment in human capital at the patient care, unit/team, and organization levels to improve patient safety. Patient Care Level An inadequate infrastructure, both technical and human, has prompted health care organizations to rely on nurses to help implement new safety programs and to enforce new policies because hospital leaders often have limited ability to disseminate or enforce such changes with the medical staff. Unit or Team Level At the team or nursing unit level, there is little or no infrastructure to develop, implement, and monitor safety projects. There is limited unit-level support for safety projects, and the resources that are allocated come from overtaxed department budgets. Organization Level: Hospital Level and Health System Infrastructure is needed to design, implement, and evaluate the following domains of work—measuring progress in patient safety, translating evidence into practice, identifying and mitigating hazards, improving culture and communication, and identifying an infrastructure in the organization for patient safety efforts. Reflections Fulfilling a commitment to safe and high-quality care will not be possible without significant investment in patient safety infrastructure. Health care organizations will need to determine the cost-benefit ratio of various investments in patient safety. Yet, predicating safety efforts on the mistaken belief in a short-term return on investments will stall patient safety efforts.

Article-at-a-Glance 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.

Problem Venous thromboembolism (VTE) is a common cause of potentially preventable mortality, morbidity, and increased medical costs. Risk-appropriate prophylaxis can prevent most VTE events, but only a small fraction of patients at risk receive this treatment. Design Prospective quality improvement programme. Setting Johns Hopkins Hospital, Baltimore, Maryland, USA. Strategies for change A multidisciplinary team established a VTE Prevention Collaborative in 2005. The collaborative applied the four step TRIP (translating research into practice) model to develop and implement a mandatory clinical decision support tool for VTE risk stratification and risk-appropriate VTE prophylaxis for all hospitalised adult patients. Initially, paper based VTE order sets were implemented, which were then converted into 16 specialty-specific, mandatory, computerised, clinical decision support modules. Key measures for improvement VTE risk stratification within 24 hours of hospital admission and provision of risk-appropriate, evidence based VTE prophylaxis. Effects of change The VTE team was able to increase VTE risk assessment and ordering of risk-appropriate prophylaxis with paper based order sets to a limited extent, but achieved higher compliance with a computerised clinical decision support tool and the data feedback which it enabled. Risk-appropriate VTE prophylaxis increased from 26% to 80% for surgical patients and from 25% to 92% for medical patients in 2011. Lessons learnt A computerised clinical decision support tool can increase VTE risk stratification and risk-appropriate VTE prophylaxis among hospitalised adult patients admitted to a large urban academic medical centre. It is important to ensure the tool is part of the clinician’s normal workflow, is mandatory (computerised forcing function), and offers the requisite modules needed for every clinical specialty.