Massachusetts Association for Healthcare Quality (MAHQ)

Spring 2018 Newsletter

President's message

Greetings MAHQ Members!
Please take a moment to register for our Annual Meeting!  We have been working hard to bring you an engaging day full of learning, inspiration and thought-provoking sessions.  Our theme this year is “Patient-Centered Care” which will be kicked-off by our Keynote Speaker Tanya Lord.  Tanya has a very personal story to share which will remind us of the value of including the patient and family in all that we do.  We are also planning to feature a panel of patients who will bring a unique perspective to our vision of health care today.  Our day will conclude with terrific presentations by Newton Wellesley Hospital and Floating Hospital for Children at Tufts Medical Center.  It promises to be one of our best conferences yet, so don’t miss it!
We are offering a “Join and Attend” option to renew your MAHQ membership at the same time you register for the meeting.  We continue to work hard to provide value to our members.  This year, we have featured several educational events including a “Quality Tool Box” webinar series, and a very well-attended and received CPHQ course for those seeking to be certified in Health Care Quality.

Have you thought about becoming a Certified Professional in Healthcare Quality?  MAHQ is offering a Professional Development Grant to current members in good standing who wish to pursue the CPHQ credential.  The grant can also be used by a member who has a current CPHQ certification that wishes to attend an educational conference.  Up to two $500.00 grants will be awarded at our Annual Meeting.  Applications are being accepted through April 30th, see our website for further details.
Thank you so much for taking the time to read our MAHQ newsletter.  We have a dedicated team of members that work hard to publish interesting and current information.  We would love to hear feedback from our members, and any suggestions you have for additional ideas.
We’ll be looking forward to seeing everyone at the MAHQ Annual Meeting on May 17th!

Best regards,
Debra Blyth-Wilk
MAHQ President

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Patient and family centered care

Eileen Hession Laband, RN, MBA, NE-BC, CPHQ & Juanita Prescod, CPHQ

Medication management is an important quality indicator for healthcare organizations. Studies show that patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines, are 30% less likely to be readmitted or visit the Emergency Department than those who lack this information. (Anthony, David, et al. “A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial.” Annals of Internal Medicine, 2009 Feb 03; Vol. 150 (3), pp. 178-87.
In fiscal year 2017, Healthcare Consumer Assessment of Healthcare Providers and Services (HCAHPS) scores for Communication about Medications at Beverly and Addison Gilbert Hospitals were less than our goal of 62.9% and our percentile rank was below 50. Feedback from patients indicated opportunities for improvement. In addition, the organization was not collecting full incentive payments for this patient experience measure for Value-Based Purchasing and Pay for Performance Contracts.
Two questions comprise the Communication about Medications Domain. They are:

  1. Before giving you any new medicine, how often did the hospital staff tell you what the medication was for?
  2. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

Organizations must achieve high performance in top box score (always) to earn incentive dollars.
To address this issue, staff in the Performance Improvement (PI) Department formed partnerships with nurses on the medical, surgical and maternity inpatient units. Using the Model for Improvement (developed by Associates in Process Improvement; http:\\, the teams implemented rapid cycle tests of changes and evaluated which were most effective.
Pre-intervention survey data was collected from nurses and patients. The nurse survey data revealed that there was wide variation in how medication teaching was done. The patient survey data showed that medication teaching was not particularly effective. On one unit, less than half of the patients surveyed knew the name of their medication. Less than a quarter could state the common side effects.
Developing standard work was one of the first goals of the PI partnerships. One unit developed short medication teaching sheets to give patients with their first dose. The information was edited down from multiple page long handouts that were usually given to the patient at discharge. They also began using the term “side effects.” Prior to implementation of the project, many nurses reviewed common reactions to medications but did not necessarily refer to them as side effects.
Other interventions included writing medication names on the white board, posting reminders to nurses on computer workstations and using brightly colored folders for medication sheets. Progress was noted on huddle boards and reviewed regularly at staff huddles.
With the consistent attention to these practice changes by nurses, educators, managers and PI staff, the units began to see positive results in their HCAHPS survey scores. The interventions were implemented in August 2017 and by the first quarter of fiscal year 2018 (Oct-Dec), the domain score for all units combined had increased to 66.9% and the percentile rank to 67 (See graph). This score for Communication about Medications placed the organization as one of the top ten performers in the Press Ganey Massachusetts Peer Group for that quarter. Although the units are celebrating their success, they realize that continued focus on this initiative is necessary to sustain the gains.

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committee member spotlight
Rita J. Morin, MSN, RN
Director, Quality and Performance Improvement
St. Joseph Hospital

An Interview by Lynn Keeley, M.ED., CHES

Lynn: Would you please share a brief overview of your career?
Rita: I have been in healthcare since I was a teen. I began as a candy striper at age 13, back when we cared for patients.  At 14, I was a cook in a half-way house where I dispensed cups of medications to the residents along with the evening meal. By age 15, I worked as a Licensed Nursing Assistant (NH designation) in long-term care. I started my ADN program right out of high school and I took my first job in NH at Southern NH Medical Center, formerly Nashua Memorial.

I moved to Illinois for 18 years and spent the majority of that time at a small critical access hospital. I served in several roles while there, including the Director of Long-Term Care. I also worked at several Level 2 trauma centers in critical care, and the Emergency Department. I even did a stint on the hospital ambulance service (in my spare time). Most of my career has been in emergency care although I have did gain experience in surgical services and intensive care.

While completing my BSN, I worked as a nursing supervisor. Then I moved role in quality. I continued to work in the ED, Urgent Care and as a supervisor until I started my role at Tufts in 2013. I completed my MSN in 2015 with a focus in nursing leadership. In 2016 I began my director role at St. Joseph Hospital just down the street from where I started.

Lynn: Which aspect of your current position is especially rewarding?
Rita: I appreciate the role quality plays in patient safe and for that reason I particularly enjoy accreditation. Everything we do in the quality department impacts patient safety in one way or another, however I feel that the work we do around accreditation is the most tangible.

Lynn: Has any one individual greatly influenced to your career? 
Rita: My greatest mentor passed away a few years ago. Kathy Johnson worked with me when I was with HCA. She was a very ethical person, with a no-nonsense way of dealing with problems. She taught me that integrity is the most vital skill in our role. The data is the data - good, bad or ugly. She also showed me that I am not accountable for others’ poor outcomes. I am responsible for showing them where they are not meeting standards or evidence based practice and helping them to succeed. I can’t do it for them; that is not sustainable. Any improvement is not an improvement if it cannot be sustained. That was a very powerful lesson.

Lynn: What led to your involvement with MAHQ? 
Rita: I was encouraged by my mentor, Kathy to join the NH group. That group was winding up so she suggested I reach out to MAHQ, even though I worked in NH. After my first event with MAHQ, I approached Lynn Myers and asked how I could be involved. She and Nina Raucher embraced my desire to help and I joined the program committee. I have remained on the program committee since then.

Lynn:  What are your goals as a MAHQ Board Member?
Rita: I would like to engage more members from NH. We have a number of us in MAHQ already but I would like to see us grow that number and expand regionally. I have also been a member of the Maine AHQ for a number of years now. I hope to collaborate with them as they have a very robust group and many creative ways of partnering with other organizations. Finally, I would like to see us offer our CE’s for the webinars on-demand. We have the recordings and they are available usually on YouTube for free and we have the CE authorization for a year. So we could potentially offer the CE’s after the live program.

Lynn:  How do you see the role of quality in healthcare organizations changing?
Rita:   As fewer manually chart abstracted process measures are being required and more outcomes based measures are being added to our reimbursement structure, I see us moving more to a collaborative consultant role. Diving into the records to see why people are returning to the hospital for care after discharge or procedures is one example. That can help us determine what led to a poor outcome and what we can change in our process to avoid that in the future. Our ability to see beyond the data, and interpret standards in a meaningful way to those who directly care for patients is key. We need to partner with coding and CDI to assure accuracy as more measures are based on coded data. We need to look at our post-acute treatment plans to improve outcomes and decrease costs. Lastly, we must assist providers in meeting objectives for patient wellness and shared decision-making. The role in quality is across the continuum of care and that will change how we now just think about the episode of care.

Lynn: How do you balance your demanding professional life with your personal life?
Rita: Well it is much easier now that all my children are grown. I have less “work” to do at home now, although I do find myself being called as a “consultant” in that arena as well. It is nice to know that eventually your children come around to realizing that “Hey Mom and Dad might actually have a clue.” It’s amazing how smart you become once your children are on their own and understand that they might not actually know everything. My husband is extremely supportive, despite the fact that I probably wouldn’t remember to come home from work if he wasn’t texting me asking what I wanted for dinner. That truly makes all the difference.

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Performance Improvement Corner
Driver Diagram
by Taruna Banerjee, MPH

The Driver Diagram is a powerful tool that helps us translate a high level improvement goal into a logical set of goals and projects.  It’s a simple, visual tool that captures the system we are working in, its outcomes, and the processes that drive the outcomes. It captures an entire change program in a single diagram and also provides a measurement framework for monitoring progress.
Image result for driver diagram template
Two Types of Driver Diagrams:
Primary Drivers:

  • System components that will contribute to improving outcome(s)

Secondary Drivers

  • Elements of the associated primary drivers that help create changes
  • Interventions expected to affect primary drivers and thus outcomes
  • Evidence-based: clinical or other types of evidence
  • Necessary and sufficient for improvement

Driver Diagram Procedure:

  • Start with a clearly defined goal.
  • Brainstorm potential drivers - the areas where change will impact on your aim.  Concentrate on generating ideas for drivers at this stage.
  • Once you’ve completed the brainstorm then cluster the ideas to create an agreed set of ‘drivers’.
  • make sure you use language like “improve” or “decrease” and that each driver is clearly defined (and potentially measurable).
  • Now you can identify the links between the drivers – creating primary, secondary and tertiary drivers – and set these out in the diagram format.
  • Add actions or interventions (change idea) for each driver.
  • Finally, decide which drivers and interventions that you want to measure and add those to the diagram.
Source: American Society for Quality 


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please join us for the MAHQ Annual meeting and program!

This year's theme:  Patient Centered Care

Thursday, May 17, 2018
8:00 AM - 3:30 PM

Covenant Health Conference Center  
Tewksbury, MA  01876

Come and hear our keynote speaker, Tanya Lord, the Director of Patient and Family Engagement Foundation for Healthy Communities in Concord, New Hampshire, as she discusses the importance of partnering with patients to reduce harm.

Tanya's passion, initiated by tragedy, is sustained by hope for a safer healthcare system.

Other Presentations Include:

Keeping Patients and Families in the Center of Rounds
Lisa Capra, MD and Maria Lombardi, RN
Floating Hospital for Children at Tufts Medical Center

Employee Development for Patient-Centered Care
Chris Oginz, Patient Experience Leader
Newton Wellesley Hospital

Cost to Attend:

Members of MAHQ or other New England state chapters with 2018 dues already paid


Join/Renew & Attend





Please note that NAHQ membership alone does not qualify for member discount.

Program is pending for 5.5 hours of continuing education credit.

Register Now!

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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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