Massachusetts Association of Healthcare Quality (MAHQ)


 Summer 2015 eNewsletter

A Message from the President...

     I am pleased and honored to begin my term as president of the Board of Directors of MAHQ. It is especially gratifying to be working with an extraordinary Board that has enormous energy and passion for advancing healthcare quality. 
I especially want to welcome our two new Board members, Jennifer Fexis of Franciscan Hospital for Children and Debra Pelletier from North Shore Medical Center.  We are very excited to have these talented quality professionals join us. 
The Program and Membership Committees are already hard at work planning programs and benefits of membership for the coming year.  You will hear much more in this newsletter and coming months about these plans. 
     Please consider volunteering to support our association.  MAHQ offers a variety of volunteer opportunities. We have positions on one of the standing committees or specific assignments, such as social networking coordinator. We are looking for people to write for our newsletter, help plan programs, be a quality mentor or be a subject matter expert. 
      For details about volunteer opportunities, please visit our website. I look forward to working with you.

Lynn Myers

Past President's Message...

     As the past President of the Massachusetts Association for Healthcare Quality (MAHQ) I wanted to take this opportunity to share our “year in review” and highlight a number of our accomplishments. Our year began at our annual retreat last June and the Board established a number of goals, including enhancing fiscal growth and viability to support advancement of mission related activities, expanding curriculum content to attract HCQP practices across various settings/disciplines, increasing membership and enhance partnerships with state/regional organizations that have an interest in healthcare quality/safety.
     I am very pleased to share that we achieved these goals and more. We increased our total assets by 24% and ended 2014 with a balance of $39,376.22. Our Program Committee hosted a number of educational events, including a conference in September with Sandra Murray titled, “Making Improvement Happen Faster: What We’ve Learned the Hard Way!” In October, they sponsored a Lean Six Sigma webinar series, titled “Lean Six Sigma and Human Performance Technology”.  Continuing their fine series in January, 2015 they hosted “Improving Patient Outcomes with Lean and Six Sigma” and finally, in March, 2015 they presented “Applying Lean Principles to Increase Patient Safety & Quality”.
     Our membership increased to 152 MAHQ members in 2014 with almost half of our membership renewals. In March 2015, MAHQ was proud to co-sponsor a webinar with the Massachusetts Coalition for the Prevention of Medical Errors, titled, “Promoting Patient Safety through a Multidisciplinary Approach to Alarm Management”.
In closing, I want to thank the 2014 Board of Directors for all their hard work and support over the past year. Additionally, MAHQ could not have accomplished so much last year without the assistance of our volunteers. A heartfelt thank you goes out to the following volunteers:

  • Shelly Bazes, RN, MS, NP
  • Edward Donahue, RN, MBA, CPHQ
  • Rita Estey, RN   
  • Alma Pelletier, RN, MSN              
  • Theresa Trainor, LPN, BS, CPHQ
  • Umber Shafiq, MPH
  • Jeanne Desfresne, CPHQ
  • Casey Joseph, MPH, CPHQ, LSSBB
  • Leigh Simons, MPH
  • Marilyn Pennachio, RN, BSN, CPHQ
  • Donna Eannuzzo RNC, BSN
  • Eileen Laband RN, MBA, NE-BC, CPHQ
  • Kimberly Smith DNP, RN, ACNS-BC, GCNS-BC, CPHQ, CMAC
  • Nancy Epstein Kerins, CPHQ

Kim Botan

Treasurer's Report

The assets of MAHQ as of March 2015 are $47,933.62.  Total income through Q1 2015 is $12,610.21.  This income was generated by program fees, membership dues, fundraising, and bank account interest.  Specifically, MAHQ received revenue from 3 webinars that were completed in the first quarter of the 2015 and recognized prepaid dues from 2014.   Total expenses for this same time period were $4,052.81.  MAHQ expenses are related to administrative, program, operational, networking and marketing expenditures.  The net income for 2015 as of March was $8,577.40.  

Detailed quarterly financial statements are posted for your review at

Respectfully submitted,

Anne Boffa


A Plan to Address Opioids Misuse, Addiction and Overdose in Massachusetts
By: Kimberly A Smith MSN, RN, ACNS-BC, GCNS-BC, CPHQ, CMAC

The campaign for adequate pain management has been strong and effective. Pharmaceutical companies added new medications to their inventories and aggressively marketed their products. Clinicians and patients have been educated and monitored to be sure patients’ pain was reduced. A by-product of this medication promotion frenzy has been a lack of overall therapeutic management for some patients, partially due to limited relevant research guiding clinician best practice. What we now know is medication overdose is the leading cause of death by injury in the United States. The mortality rate of opioid addicts is 6-20 times greater than those who are not opioid addicts (Hser, Y., Evans, E.E., Grella, C., Ling, W., & Angli, 2015). Treating the acute pain of an opioid-naive emergency department patient increases that patient’s risk of additional opioid use at 1 year (Hoppe, Kim, & Heard, 2014).

The need for a structured pain management plan was recognized and addressed by the Massachusetts Hospital Association (MHA). In April 2015, the MHA Guidelines for Emergency Department Opioid Management was released to offer providers strategies for screening patients and appropriately prescribing opiates and a Hospital Commitment to ED Opioid Management agreement was developed. It is encouraging to know such programs have been successful. For example, Fox, Li, Stevens, & Tippie (2013) reported a reduction in the rate of opioid prescriptions and emergency department visits for patients with dental pain following the adoption of a prescribing guideline. Will the MHA guidelines make a difference? That question can be answered only if the guidelines are integrated into practice. 

Federal Drug Administration. (2014). FDA blueprint for prescriber education for extended-release and long-acting opioid analgesics. Accessed 6/7/14.

Fox, T. R., Li, J., Stevens, S., & Tippie, T. (2014). A
performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine, 62(3), 237-240.

Green, S. (2012). There is oligo-evidence for oligoanalgesia. Annals of Emergency Medicine. 60(2). 212- 214.

Grover, C. A. & Garmel, G. M. (2012). How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain? The Permanente Journal, 16(4), 32-36.

Hoppe, J.A., Kim, H., & Heard, K. (2015). Association of emergency department opioid initiation with recurrent opioid use. Annals of Emergency Medicine, 65(5), 494-499.

Hser, Y., Evans, E.E., Grella, C., Ling, W., & Anglin, D. (2015). Long-term course of opioid addiction. Harvard Review of Psychiatry. 23(2), 76-89.

Institute of Medicine (2011). Relieving Pain in America. A blueprint for transforming prevention, care, education, and research. Washington, D.C.: The National Academies

Suzuki, J., Meyer, F. & Wasan, A. D. (2013). Characteristics of medical inpatients with acute pain and suspected non‐medical use of opioids. The American Journal on Addictions, 22, 515–520.


Program Committee Update

Over 75 MAHQ Members and guests attended the MAHQ Annual Meeting April 16, 2015 at the Massachusetts Hospital Association offices in Burlington, Massachusetts.  The topic of this Annual Meeting was Population Health Management: Controlling Cost, While Ensuring Quality.

  • Michael Cantor, MD, Chief Medical Officer at New England Quality Care Alliance (NEQCA) where Dr. Cantor is responsible for NEACA’s 1,800 physicians work to achieve contractual targets based upon the Triple Aim Goals: better health, better patient experience of care, and lower cost.  The focus of Dr. Cantor’s presentation was on working with a large, diverse physician network, share the results of their quality improvement efforts, lessons learned and implications for the future in an effort to achieve their Triple Aim Goals.

  • Dana Gelb Safran, Sc.D., Senior Vice President of Performance Measurement and Improvement at Blue Cross Blue Shield of Massachusetts (BCBSMA). In this role she leads the company’s initiatives to measure and improve healthcare quality, safety, and outcomes. In 2009 BCBSMA introduced the Alternative Quality Contract (AQC), a payment reform model with the twin goals of significantly reducing health care spending growth, while improving quality and health outcomes. Dr. Safran’s presentation outlined the impetus for AQC development, the results achieved under payment reform in Massachusetts; highlight the challenges ahead in advancing payment reform nationally, and the implication for provider organizations.

  • Michael Jellinek, MD, Executive Vice President, and Chief Executive Officer of the  Community Network at the Lahey Health system. In his role, Dr. Jellinek is responsible for population health management and building Lahey community resources into a system of care. Dr. Jellinek’s presentation focused on the dramatic changes in healthcare, implications of risk contracts, and population health management, including drivers of healthcare reform, healthcare costs, and transitions.

  • Neil Wagle, MD, Associate Medical Director in Population Health Management at Partners Healthcare. In Dr. Wagle currently leads Partners effort around ambulatory quality measurement and performance, including Patient-Reported Outcome Measures Program and the use of clinical registries for quality measurement. Dr. Wagle’s presentation discussed the shortcomings of the current state of ambulatory quality measurement and some ways that ambulatory quality will need to proceed, including how current quality concepts might be measured differently using clinical registries, specialty metrics, and Patient-Reported Outcome Measures.

Based on the program evaluation MAHQ members and guests felt the presenters were extremely knowledgeable, felt there was a lot of information covered, and they walked away with more information.

Membership Committee Update

We are off to a successful membership drive this year. We currently have 147 individual, 3 organizational and 1 student member. See MAHQ individual membership data over time:

We are not yet at our goal of 175 members for this year! Recommend a colleague or your organization to join.  We are still offering our three membership levels. Go to the MAHQ website to learn more and complete the form on line or download and mail in with your payment.  The membership data will be used to determine the types of programs we offer, networking events vs. webinars and the location of events.


Committee Member Spotlight: Debra Pelletier, MSN, RN
by: Eileen Hession Laband, MBA, RN, NE-BC, CPHQ

This month our Committee Member Spotlight shines on Debra Pelletier, MSN, RN, who has been on the Membership Committee since April 2015.  Debra is currently the Director of Professional Practice at North Shore Medical Center (NSMC). In this role she is responsible for the assessment, development, enhancement, and evaluation of nursing practice.  Responsibilities include participating in program management for the Nursing Professional Practice Council and Collaborative Governance program at NSMC; supervising and supporting unit-based educators; facilitating school of nursing affiliations, student placements and innovative partnership models; fostering new graduate nurse practice, preparing unit-based preceptors and overseeing the development, revision and approval of practice standards and protocols. Debra co-chairs NSMC Nursing Grand Rounds and the Nursing Peer Review Council.

Prior to that Debra was the Director of Cardiovascular Nursing at NSMC. As an active committee member, Debra brings a passion for excellence in nursing practice and the quality of care delivered.  Quality is central to nursing practice and each informs the other by working synergistically to produce excellence in patient outcomes.   

EHL: How did you get interested in a career in healthcare? 

DP:  I’m afraid I will give my age away when I tell you that I was a candy striper in high school.  My parents instilled in their children the value of volunteer work and my experiences as a candy striper were formative. 

EHL: Who has been influential in your career in healthcare?

DP:  I’ve been influenced by three outstanding nurse leaders throughout my career as a registered nurse.  I was at the bedside as a clinical staff nurse for 20 years before transitioning to a nursing leadership role.  While a staff nurse, I was always encouraged to seek out leadership roles but did not know what I wanted to do “when I grew up” and I was focused on raising my daughters.  Once I had experience in a leadership role, I knew immediately that I wanted to continue to grow in my profession and sought progressive experience that shaped who I am today.

EHL: What is your favorite part of your job?

DP:  It is hard to define my favorite part of my job but I would have to say it is enhancing the practice environment for our clinical staff so that they can perform their job to the best of their capabilities. I also enjoy developing staff and participating in nursing peer review.  My passion is developing staff and future nurse leaders.  One measure I use to determine if I have been successful is to reflect on the past year to see if I have contributed to the ongoing development of, a colleague, a staff nurse, a shared governance council member, or any of my direct reports

EHL: Why did you get involved in MAHQ?

DP: A colleague reached out and recommended I consider being involved with MAHQ.
I am so glad I took her advice.

EHL:  How has your involvement benefitted you?

DP: This experience is brand new and I am excited for the

future and look forward to playing an active role on the MAHQ board.

EHL: What do you like to do in your spare time?

DP:    I am a new grandmother with two beautiful granddaughters and a grandson on the way.  At this time in my life, I get to spend a great deal of time with them and wouldn’t miss it for the world.  I am lucky to balance the demands of this fast-paced healthcare world we live in by gardening – it is a wonderful stress reliever. 

EHL: Thank you for your time and your service to MAHQ.

DP:    I very much appreciate this opportunity to share a little bit about myself with you and look forward to contributing to the work ahead.


Share your talents with MAHQ! 

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.
MAHQ offers a variety of volunteer opportunities. We have positions on one of the standing committees or specific assignments, such as social networking coordinator. We are looking for people to write for our newsletter, help plan programs, be a quality mentor or subject matter expert

For details about volunteer opportunities, please go to:


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:


Websites of Interest
Health Leaders 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.

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Kimberly A. Smith, DNP, RN, ACNS-BC, GCNS-BC, CPHQ, CMAC
Lawrence General Hospital