This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the Armstrong Institute for Patient Safety and Quality. The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff members, 140 core faculty, and an annual budget of about $15 million. The new governance structure includes oversight from a patient safety and quality board committee. The overall goal of these efforts was to achieve quality metrics that would meet the requirements for the Delmarva Foundation Excellence awards and The Joint Commission's Top Performer award at each of the 5 Johns Hopkins hospitals (2 academic and 3 community institutions). By 2013, the health system reached at least 96% compliance on 6 of 7 targeted measures, with 4 hospitals receiving the Delmarva Foundation award and 2 hospitals garnering the Joint Commission award, making a strong case for the effectiveness of this robust high-reliability strategy.