This study on BMJ Open reports on the successful stratification of patients with inflammatory bowel disease (IBD) based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring. A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using ‘PlanDo-Study-Act’ cycles within the ‘Model for Improvement’ framework and analysed data continuously using statistical process chart.