Massachusetts Association for Healthcare Quality (MAHQ)

Spring 2017 Newsletter

President's message

I hope you all had a wonderful holiday season.  I wish you a healthy, happy, and safe 2017. 
We are excited to announce our Annual Meeting which will be held on Wednesday, April 5, 2017 at the Massachusetts Hospital Association suite in Burlington. Please plan to attend!  The theme for the day is “Transforming Healthcare through High Reliability”.  We are honored to announce that we already have the following distinguished keynote speakers: Ann Scott Blouin from The Joint Commission and Monica Kleinman from Children’s Hospital.  I am sure they will have great insights for us!

Consider joining the MAHQ Board this spring. It is a great way to get involved in working across the state to improve healthcare quality. Your commitment would be just a few hours each month. We meet in-person twice a year and via conference call during the other months. We have an enthusiastic group who are committed to working together across the continuum of care to improve patient quality and safety. And, we’d love to have you join us!

Welcome to our new members in 2017! We hope you will join us by contributing to its present activities, future growth and sustainment. We look forward to an exciting year ahead and want to learn more about you! Share your accomplishments, contribute an article or volunteer for a member interview. If you're not a member yet or have not renewed your membership, please visit the membership page on our website to join or get involved!

Cheryl Hafela RN, MSN, CPHQ
President, MAHQ


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MAHQ Annual Meeting


Massachusetts Association of Healthcare Quality, Inc
2017 Annual Meeting
Please join us for the MAHQ Annual Meeting and Program!
Wednesday, April 5, 2017
8:00am-3:30 pm
Massachusetts Health & Hospital Association (MHA)
Burlington, MA 01803

This Year’s Theme:
Transforming Healthcare through High Reliability

The Joint Commission will join MAHQ to cover the three principle tenants (pillars) of High Reliability: Leadership, Safety Culture, and Robust Process Improvement. 

Ann Scott Blouin, Executive Vice President of Customer Relations at The Joint Commission will define the elements of a safe culture, which can help enable highly reliable healthcare, describe the conditions underlying psychological trust, and identify environmental and human preconditions for a culture of reliability and safety.

Presentations by:

Main speaker:   
Ann Scott Blouin, The Joint Commission
Guest speakers:

Monica Kleinman, MD, Boston Children’s Hospital

Members = $125 (includes MAHQ + New England State Chapters)
Meeting + Membership Dues = $165
Non-members = $185


Program is pending for 5 contact hours of continuing education credit

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Call for Posters

If you presented a poster in 2016, MAHQ would like to extend an opportunity for you to share your poster with your healthcare quality professional colleagues at the MAHQ Annual Meeting on April 5, 2017 at the MHA in Burlington, Massachusetts.
If interested in sharing your poster please click here to complete an online form for review by the Program Committee’s Poster Sub-committee.

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Volunteer Opportunities

MAHQ relies on skilled volunteers with diverse experiences in healthcare quality who dedicate their time to support and promote the Association’s mission and activities. Volunteering not only provides opportunity for  business and professional growth, enhancing skills or competencies, personal recognition, but also giving back through service to others.  If you know a colleague or student encourage their participation. For details about volunteer opportunities, please go to

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An Original Article
by Eileen Hession-Laband, RN, MBA, NE-BC CPHQ

Employee Engagement - A Vital Link to Quality, Safety and Financial Returns

Are you eager to get to work each morning?  Do you feel energized by your work and look to make a difference each day?  If so, then you are a highly engaged employee and your dedication and skills are what all employers are seeking.
A number of recent healthcare studies demonstrate that the most powerful improvements organizations can make in patient care and satisfaction are able to be achieved merely by improving employee engagement.  A study in the British Journal of Nursing demonstrated a link between increased levels of engagement of nursing staff and improvements in avoidable harms.1 In a study conducted in 168 Pennsylvania hospitals, patients had significantly lower risks of death and failure to rescue in hospitals with better work environments. 2
Patients notice when employees are engaged and their responses on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) indicate this.  Gallup research shows that high levels of engagement are linked with high HCAHPS scores.  3
Meeting quality of care goals and patient satisfaction targets can mean hundreds of thousands of dollars from value-base purchasing. Other financial incentives for employee engagement are turnover costs, length of stay charges and malpractice claims payments.
All of this research makes a compelling case for healthcare organization to ensure that their employees are engaged. Yet one global workforce study revealed that less than half (44%) of U.S hospital workers are highly engaged. 4  This finding demonstrates that the majority of employees from various roles and settings feel disconnected from their organization and their job.
So what can organizations do?  Healthcare leaders play a critical role and can advance the agenda of employee engagement by identifying issues within the culture that hinder engagement. Senior leaders need to set the expectations and hold others accountable. They need to make sure leaders are aligned, engaged themselves and are skilled in hiring, coaching and developing their staff.
Some specific steps for healthcare leaders on this journey:

  1. Create a shared vision for change. Examine “Where are we as an organization right now and where do we want to be?”
  2. Establish values that support the vison and set expectations for specific standards of behavior.
  3. Be a role model and consistently demonstrate the core values.
  4. Align resources to support expectations and priorities. If you say patient experience is important, devote the necessary resources.
  5. Establish systems of accountability.  Include behavioral standards in performance evalutions. Address concerns and recognize performance through rounding, coaching and one-on-one discussions.
  6. Track and share organizational performance of service and quality targets.
  7. Share success stories and celebrate.

As healthcare leaders the challenge is before us. We must work tirelessly to ensure we have an engaged workforce so we can achieve our safety, quality and patient experience goals.


  1. Day, H. (2014). Engaging staff to deliver compassionate care and reduce harm. British Journal of Nursing, 23(18), 974-980
  2. Aiken LH, Clarke SP, Douglas M. Sloane DM,  Lake ET,  Cheney T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. J Nurse Adm, 38 (5): 223-229.
  3. Burger J. (2014) Why hospitals must surpass patient expectations. Gallup Consulting. Accessed on February 22, 2017.
  4. Sherwood R. (2013) Employee engagement drives health care quality and financial returns. Harvard Business Review. Accessed on February 21, 2017 at

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MAHQ Professional Enhancement Grant awarded

MAHQ is pleased to announce that Lynn Keeley was awarded the 2016 MAHQ Professional Enhancement Grant.  Lynn works in Quality and Patient Safety at Whittier Rehabilitation Hospital. 
Lynn plans to use the grant to pursue CPHQ certification. 
We received several excellent applications and the Finance Committee had a hard time deciding.  The applicants all spoke eloquently about their desire to improve their knowledge and skills and to be advocates for patients and their families by improving the systems of care delivery.
Congratulations to all the applicants.

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2017 Patient Safety Forum – Improving Patient Safety, Improving Value
March 30, Sheraton Framingham
7:30 AM Breakfast and Registration
8 AM – 2 PM Program (including lunch)

You are invited to attend the 2017 Patient Safety Forum co-provided by the Massachusetts Coalition for the Prevention of Medical Errors and Healthcentric Advisors.

  • The program will share highly leveraged strategies that enable organizations to accelerate their improvements in patient safety and all elements of value, and specific projects that have already shown results.
  • Create the will for needed changes, and support effective execution
  • Enable leaders to address the many demands in the current environment
  • Integrate performance improvement to address patient safety and other quality/triple aim goals
  • Enhance clinician and staff engagement and reduce overload/burnout

The Forum will share strategies and show results from multidisciplinary teams, leadership and front-line teams, and settings including community hospitals, academic medical centers, and ambulatory services.

To register, visit

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Jeanne Dufresne, MAHQ Director & Program Committee Chair

An interview by Amada Voysey, MAHQ Director

Amanda: How did you get interested in a career in healthcare? 
Jeanne:   I have loved the world of quality ever since being introduced to it in 2005.  I took a position at Quincy Medical Center as a quality data analyst and professionally I grew into so much more.  The exposure to Quality and Risk Management and the regulatory compliance that goes into all that work has always held a particular interest for me.  I was fortunate enough to have leaders who believed in me along with RNs who would take any moment of the day to answer a question I had.  They were the people who gave me all the right “chances” to grow.  Prior to that position, I started as a data entry specialist for a long-term rehab.  Again, I had the opportunity to grow and moving from the rehab to acute care seemed the next natural step.  Folks from both settings really had an impact on where my career has gone and the ability to work at a regional level with multiple health care settings has everything to do with all the support that was there for me.

Amanda: Who has been influential in your career in health care? 
Jeanne: The leaders I have worked for have had a very big influence in my career.  It was one of those leaders who insisted I apply for my CPHQ.  Due to her insistence, I am CPHQ certified.  The other influences have been the nurses and physicians I have had the pleasure working with.  They have had a tremendous influence on me in ways I would have never imagined.  They are passionate about their work and will take any teachable moment allowed them to sit and educate.  This was apparent and abundant when I began this journey.  I will always be grateful for them.

Amanda: What is your favorite part of your job? 
Jeanne: Educating healthcare staff who have to navigate the CMS reporting programs.  I now can educate external staff along with my internal team and I feel like I can give back even if it is in a small way.  Healthcare is about the people who are taken care of however there is the work behind the scenes that makes certain facilities and staff are providing quality care for all.  That is where I can support and assist.

Amanda: Why did you get involved in MAHQ? 
Jeanne: Everything that MAHQ offers, from webinar events to in-person conferences has folks who work very hard to make certain everything comes together.  I enjoy being a part of that process.  It also provided an opportunity for me to expand my experience and me.  I am still learning, 15 years later and I welcome that chance.  I have been exposed to different things I may not have been otherwise due to my involvement with MAHQ and am grateful for the folks I have the pleasure of working with.

Amanda:  Where do you think healthcare in Massachusetts is headed? 
Jeanne: It is more uncertain today than ever before but I feel that Massachusetts is a leader in the healthcare world.  New innovations and technologies are developed here along with the best clinical professionals and hospitals in the world.  I see that continuing for many years.  I also see Massachusetts as the forerunner for anything healthcare.  Many healthcare pilots are started here and I see this state as staying a strong advocate for healthcare.

Amanda: What do you like to do in your spare time?
Jeanne: Play games on my IPhone is something that helps me unwind.  I now have my first audio book “Born to Run”, Bruce Springsteen, and am enjoying listening to that very much.  I recently saw Bruce Springsteen in concert and it was amazing!
I also love to watch the Patriots and the Red Sox and when we can my husband and I will try to get to Pawtucket for a Paw Sox game.

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Performance Improvement Corner
by Taruna Banerjee, MPH

In this issue of the MAHQ newsletter, we are featuring Control Charts and Statistical Process Control.

Control Chart

This is called a statistical process control chart or a Shewart chart. It is a graph used to study how a process changes over time.  Data are plotted in time order and the control chart has a central line (or mean), upper control limit and a lower control limit. These lines are drawn from historical data.  By comparing current data points to these lines, you can conclude if the process is in control or affected by special causes of variation.

When to Use a Control Charts:

When controlling ongoing processes by finding and correcting problems as they occur.

When predicting the expected range of outcomes from a process.

When determining whether a process is stable (in statistical control).

When analyzing patterns of process variation from special causes (non-routine events) or common causes (built into the process).

When determining whether your quality improvement project should aim to prevent specific problems or to make fundamental changes to the process.

Control Chart Basic Procedure:

Choose the appropriate control chart for your data.

Determine the appropriate time period for collecting and plotting data.

Collect data, construct your chart and analyze the data.

Look for “out-of-control signals” on the control chart. When one is identified, mark it on the chart and investigate the cause. Document how you investigated, what you learned, the cause and how it was corrected. 

Source: American Society for Quality 

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MAHQ Newsletter Content 

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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