Massachusetts Association for Healthcare Quality (MAHQ)

Fall 2017 Newsletter

President's message

I hope everyone had a successful and engaging Healthcare Quality Week.  At the Spaulding Rehabilitation Network, we celebrated the week with several events.  We took the opportunity to engage staff in the Healthcare Quality week activities by having displays in several of our facilities highlighting the various quality improvement initiatives that are ongoing throughout the Spaulding network.  We also held a Quality Week Breakfast where the quality staff of our different sites and facilities were able to come together and share best practices, meet new staff, and reflect on the successes of the past year.  As one of my quality colleagues reminded me during the breakfast, “Quality is not a department, but a culture!”  This was a well-timed reminder for all of us!

Within MAHQ, the Board of Directors is working hard to create several educational offerings for our members.  We are offering several webinars for the winter season, aimed at staff who may be new to the field.  This is our “Quality Tool Box” series which will feature sessions in which our quality experts showcase a different quality “tool” during each webinar.  We have featured a similar series in the past with terrific feedback.

We are also busy coordinating our Annual Meeting which will be held in the spring.  The theme will be “Patient-Centered Care”.  We have several exciting speakers and topics lined-up, stay tuned for more details soon!

Finally, the leadership of MAHQ is exploring ways to expand and grow our organization.  We would like to be the premier organization for healthcare quality professionals throughout New England.  Do you have suggestions for us?  We would love to hear from you!

Best regards,
Debra Blyth-Wilk
MAHQ President

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Building a Successful Patient Experience Program with Volunteers

Spaulding Rehabilitation Hospital (SRH) in Charlestown planned to “go-live” with a new electronic health record in January of 2017.  Leaders at SRH recognized such change could affect patient satisfaction and sought innovative methods to maintain SRH’s traditionally high patient satisfaction scores.  Several months prior to go-live, the health care team recognized that a volunteer program would assist with the change. The subsequent adoption of this proposal triggered many inquiries by potential volunteers looking for an opportunity to become involved with SRH.  Many of these came from students and retirees seeking meaningful ways to contribute.  Some volunteers lived near the Charlestown Navy Yard and were available one day a month on a weekend.

The Quality and Compliance department of the hospital developed a training program for our cadre of new volunteers. The first step was to engage our Patient Experience survey vendor.  At the request of the hospital, the vendor reviewed research studies that examined the impact of the new health record adoption process before, during and after implementation.  Results of their review revealed there were mostly neutral or positive effects on satisfaction, but communication was the domain most affected by the change.  The recommendation from our vendor was that our goal should be to sustain previously achieved improvements.
 “Words that Work” was the initiative that was developed as a result of this review.  It showcased ways to assist volunteers with proven successful strategies to successfully communicate with patients proactively about the change to the new electronic health record.  Volunteers were trained with specific scripts and proactively discussed the planned change in the electronic health records with the patients.
Leadership and staff were in agreement that maintenance of the high patient experience scores was the desired outcome. When the scores were revealed for the month of the “go-live”, it was pleasing to learn some of the highest scores for patient satisfaction, i.e. 99th percentile, had been measured. In addition, scores for the entire quarter were also very high. 
This volunteer program was a very successful initiative for SRH and its evolution has come to include new components, such as the volunteers’ "survey of patient experience" the first week of their admission.  The questions now focus on areas such as satisfaction with meals, cleanliness of rooms and coordination of care.  The volunteers are an integral component of SRH’s Patient Experience Program, and their significance will continue as we move forward to improve care and satisfaction for our patients.

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Performance Improvement Corner
by Taruna Banerjee, MPH

In this issue of the MAHQ newsletter, we are featuring the PDSA cycle:

Is an iterative, four–step problem solving model used for improving a process or carrying out change. Just as a circle has no end, the PDCA cycle should be repeated again and again for continuous improvement.
Image result for pdsa cycle picture
When to Use Plan-Do-Study-Act:

  • As a model for continuous improvement.
  • When developing a new or improved design of a process, product or service or when implementing any change.
  • When defining a repetitive work process.
  • When planning data collection and analysis in order to verify and prioritize problems or root causes.

Plan-Do-Study-Act Procedure:

  1. Plan. Recognize an opportunity and plan a change.
  2. Do. Test the change. Carry out a small-scale study.
  3. Study. Review the test, analyze the results and identify what you’ve learned.
  4. Act. Take action based on what you learned in the study step. If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

Image result for pdsa cycle picture

Source: American Society for Quality 

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Online Safety Culture Assessment From The Institute For Healthcare Improvement And The National Patient Safety Foundation (IHI/NPSF)

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (IHI/NPSF) developed a 9-question assessment to help you determine where your organization stands in building a culture of safety.  The assessment can be accessed at:

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register now for the 2018 Quality toolbox webinar series

Join MAHQ as we review three key process improvement tools you need to launch and manage a successful improvement project.  Explore tools that can help you identify causes, generate ideas, and make informed decisions for all of your continuous improvement activities. 

All webinars are on Tuesdays at noon:

January 9, 2018: Cause and Effect Diagram
February 6, 2018: Driver Diagram
March 6, 2018: Failure Modes and Effects Analysis

Register now for the series or for just the January webinar. Registration opening soon for the individual February and March webinars.

Please contact MAHQ if you are unsure of your membership status BEFORE registering for webinars. All 2017 memberships must be renewed for 2018 to take advantage of member pricing. This is a great time to renew your MAHQ membership or join for the first time. Please note that NAHQ membership is completely separate and does not qualify you for member rates. Click here to visit our membership page!

MAHQ Newsletter Content or project spotlight

Do you have a quality event happening that you would like your fellow MAHQ members to know about?  Send it to us and we will include the information in our newsletter. We are also interested in original content about a successful project, recent promotions and/or any other quality news you would like to share.  Please submit articles for approval and posting to

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Connect with MAHQ!

MAHQ is on Facebook - connect with us here: for updates on programs and other opportunities. You can also keep up with MAHQ, including job postings, through our LinkedIn account:

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Websites of Interest

HealthLeaders Media
Health Leaders Media Magazine is a monthly look at the issues and trends that are shaping the business of healthcare today
View all the covers and read all the cover stories.
HealthLeaders Media Staff, for HealthLeaders Media, December 31, 2014.

The Commonwealth Fund
The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

Centers for Disease Control & Prevention
In public health settings, performance management and quality improvement tools are being promoted and supported as an opportunity to increase the effectiveness of public health agencies, systems, and services.

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