Massachusetts Association for Healthcare Quality (MAHQ)

Summer 2017 Newsletter

President's message

I am really excited to be the new President of the Massachusetts Association for Healthcare Quality.  Thank you to all who were able to attend our Annual Meeting back in April.   It was an action-packed day filled with informative presentations as well as ample opportunities for networking with our Quality Improvement colleagues! As we look forward to the coming year, the MAHQ Board is looking for ways to improve the value we provide to our members.  We have several programs ready to launch this year that we hope will engage our membership.  We have heard from members that they like the ease and convenience of webinars.  We are in the final planning stages of two webinar series.  The first will be a Quality Toolbox filled with practical suggestions for those new to quality data management or for those looking for a quick refresher.  The second webinar series will focus on the topic of “Patient Centered Care.” Following in line with the Institute of Medicine’s call for the patient to be the focus of our health care improvement efforts, we will discuss areas such as tactics to sustain and improve Patient Experience scores during implementation of a new electronic health record.  Stay tuned for more specifics!

Have you thought about becoming a Certified Professional in Healthcare Quality?  We will be offering a CPHQ Review Course in November. Our website has details about the CPHQ course and the MAHQ Professional Development grant.

Finally, as we explore ways to expand and grow our organization, we want to hear from you!  We would like to be the premier organization for healthcare quality professionals throughout New England and are considering a name change to be more inclusive.  Do you have suggestions for us? We would love to hear from you!  Let’s start a conversation as we move forward in our quality improvement journey together.

Best regards,
Debra Blyth-Wilk
MAHQ President

A Note from Our Past President

As the past President of the Massachusetts Association for Healthcare Quality (MAHQ) I would like to take this opportunity to thank everyone for a great year and share our “year in review” and highlight some of our accomplishments during this successful year:

  • Made a profit of $3,453.85 and increased our overall assets by 9.1%
  • Funded a Professional Enhancement Grant
    • Lynn Keeley will be pursuing her CPHQ certification
  • Provided a wide range of programs for members that included:
    • The first presentation of the annual meeting as a virtual event
    • A live networking event entitled “The Role of Families and Siblings in the Behavioral Health Experience” during Healthcare Quality Week in October
    • A three part webinar series (December, January, February) focused on “High Reliability”
  • Published three electronic member newsletters (Summer, Fall, Spring) featuring:
    • Original articles written by members
    • PI Corner with a “tip” or “tool”
    • Member Spotlight highlighting a MAHQ Member
  • Developed a longitudinal membership tracking process
  • Enhance membership forms with an embedded PayPal option
  • Reviewed and updated organizational by-laws

In closing, I want to thank the 2016-2017 Board of Directors for all their hard work and support over the past year. We could not have accomplished so much last year without the assistance of our volunteers who served on committees. A heartfelt thank you goes out to the following volunteers:

  • Shelly Bazes, RN, MS, NP
  • 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
  • Lisa Herlihy, RN, MSN, CCRN-CSC

Cheryl Hafela RN, MSN, CPHQ

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An Original Article

Patient and Family Centered Care
By Kimberly A. Smith DNP, RN, ACNS-BC, GCNS-BC, CPHQ, CMAC

     The Institute for Healthcare Improvement (IHI) describes Person- and Family- Centered Care as “putting the patient and the family at the heart of every care decision and empowering them to be genuine partners in their care”.  The implications of this approach are that patients and families will be educated about the available care options, have opportunity to be engaged, and have their decisions well- supported by care team members. The overarching focus of these care objectives is patient and family engagement. Providing a truly patient- and family- centered experience can require process changes with ongoing evaluations to measure patient and family satisfaction and involvement. Some barriers and challenges can be anticipated. Volpp & Mohta (2017) reported that when asked to rate the top three challenges of patient engagement in a New England Journal of Medicine (NEJM) Catalyst survey, the responding 555 health care executives, clinical leaders, and clinicians shared the following:

  • time investment by the health care team- 63%
  • patient adoption- 54%
  • provider adoption- 52%
  • cost investment- 49%
  • infrastructure development for technology approaches- 36%
  • providing supervision and follow- up- 34 %

Despite the required effort and obstacles, further tapping into patient and family engagement can be a valuable resource for quality improvement. As one of the survey respondents conveyed, “Speak to patients; ask what they want. You will be surprised.” (p. 12)
     Participatory methods are used to engage those individuals, i.e. patients, most impacted by an intervention and/or outcome.  These methods involve collecting the first-hand accounts of patients usually captured by documenting during or just after an experience. Data from these evaluations is usually qualitative rather than quantitative. Engaged participants can also potentially assist with the interpretation of the results. Balbale, Locatelli, & LaVela (2016) acknowledged further evaluation of participatory methods is necessary to effectively assess health care quality and identify needed improvements. They recommended that participatory methods be included in quality projects to facilitate the partnership between stakeholders and the health care team. The specific methods Balbale, Locatelli, & LaVela examined in their study of the Department of Veterans Affairs were guided tours, i.e. a walking interview with open-ended questions, and photovoice whereby participants use photography to document their needs, experiences, and perceptions.
Healthcare quality professionals can consider these and other participatory methods to retrieve qualitative data with the goal of improving healthcare through increased collaboration, building on existing strengths, and developing closer relationships with patients and families.

Balbale, S. N., Locatelli, S. M., & LaVela, S. L. (2016). Through their eyes: Lessons learned using   participatory methods in health care quality improvement projects. Qualitative Health Research, 26(10), 1382–1392.

Institute of Healthcare Improvement. Patient and Family Centered Care. Retrieved from   

Volpp, K. G. & Mohta, N. S., Massachusetts Medical Society. (2017) NEJM Catalyst- Patient engagement survey: How to hardwire engagement into care delivery processes. Waltham, MA.

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Lynn M. Keeley MEd, CHES
Director of Performance Improvement,
Whittier Rehabilitation Hospital, Westborough, MA

An Interview by Kimberly A. Smith DNP, RN, ACNS-BC, GCNS-BC, CPHQ, CMAC

Kimberly: Would you please share a brief overview of your career?
Lynn: My career started out and has remained in rehab.  I began as a Certified Therapeutic Recreation (TR) Specialist.  I worked between Spaulding Burbank Hospital and Emerson Hospital.  When a fulltime position opened, I transitioned to Fairlawn Rehabilitation Hospital in Worcester.  In 1997 a new hospital called Whittier Rehabilitation Hospital was opening in Westborough, so I applied and was offered a position to be part of the start-up crew.  Well, it’s now history because almost 20 years later, I am still there. In 2002 I started to get involved with Quality and Outcomes at the hospital and split my time as TR Clinical Specialist and Quality and Outcomes Coordinator.  During this period, I also started working on my Master in Health Education degree at night.  I was enjoying the new part of my role, so when an opportunity opened for Quality Assurance (QA) and Outcomes Manager in 2003, I decided to apply.  I transitioned into the QA role full time and only worked as a CTRS as needed for special cases.  In 2004 I earned my Masters in Health Education and passed the certification exam for Certified Health Education Specialist (CHES).  In 2007 there was an opening for Director of Performance Improvement to which I applied, and I have been in this role ever since.

Kimberly: Which aspect of your current position is especially rewarding?
Lynn: The most rewarding part of my current position is when we have a successful PI project and we sustain the change.  Since a lot of work and energy goes into making the changes, it is rewarding when it succeeds and usually a process is made safer for our patients and/or easier for our staff. The end result is that everyone benefits! An added benefit to my role is getting to work with staff in all departments. 

Kimberly: Has any one individual greatly influenced to your career? 
Lynn: The biggest influence on my career in quality came from a woman from our corporate level who was a big advocate for QA and patient safety. My interest in quality processes began when she visited our hospital to provide an in-service about Toyota.  Later she filled in as our DON while we were looking to hire a new one. She encouraged me to get involved in the quality role and taught me a lot about the whole PDCA process, analyzing data, and regulations.

Kimberly: What led to your involvement with MAHQ? 
I have been a member of MAHQ since about 2003 or 2004.  Working in a small hospital, I don’t have a department staff in quality, so I started to attend MAHQ events for education and networking with other quality professionals.  They always mentioned vacant positions, and every time I attended events I saw all the wonderful volunteers who make these events happen.  I inquired about volunteer opportunities years ago, but then never followed up because my kids were still too young and I didn’t have the time.  I reached out again this past year and Lynn Myers was so wonderful to educate me about what each committee and role entailed and the required time commitment.  She then reached out to me again and encouraged me to get involved with the Board of Directors.  So, thanks to Lynn, I am now officially involved! 

Kimberly:  What are your goals as a MAHQ Board Member?
Lynn: As a board member, I hope to contribute my time and energy to help our organization to continue to grow in membership, as well as, continue to educate professionals on topics that are current in the quality field.  I will do whatever is needed of me on the board to help MAHQ succeed. 

Kimberly:  How do you see the role of quality in healthcare organizations changing?
Lynn:   I see our role as quality professionals in healthcare organizations becoming more and more important due to all the regulatory and reimbursement changes that continue to come down the pike.  Quality is a critical part of healthcare and is vital when striving to be a high reliability organization with patient-centered care.

Kimberly: How do you balance your demanding professional life with your personal life?
Lynn: Balancing my personal and professional life is a challenge. I work for a family- owned hospital where we all wear many hats. Work is demanding and sometimes it seems like there are not enough hours in the day since there are no other quality staff.  The key is working closely with all departments, getting them involved in our PI processes, and working together as a team.  My personal life involves two wonderful children who participate in many sports and a husband who also has a busy job. We spend a lot of time running between work and sporting or school events for the kids.  I wouldn’t want it any other way.

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Performance Improvement Corner
by Taruna Banerjee, MPH

In this issue of the MAHQ newsletter, we are featuring the Check Sheet, allso called a defect concentration diagram.

What is a Check Sheet?

  • A check sheet is a structured, prepared form for collecting and analyzing data.
  • Data can be collected with minimal effort.
  • It’s a tool commonly used for factual problem solving. For example, assessing what events are occurring; who’s responsible for the event; when and where does the event occur?
When to Use a Check Sheet
  • When observing process variability
  • To identify potential problems 
  • When data can be observed and collected repeatedly by the same person or at the same location
  • When collecting data on the frequency or patterns of events, problems, defects, defect location, defect causes, etc.

Types of Check Sheets

1. Tabular check or tally sheet: Commonly used to collect data on quality problems and to determine the frequency of events.

2. Location or concentration diagram:  A visual map used to identify issues or problems.

Consider using a check sheet the next time you are collecting data.

Source: American Society for Quality 

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Apply for the MAHQ Professional Enhancement Grant

Is 2017 the year you plan to become CPHQ-certified?  Do you already have your CPHQ, but find budget cuts are keeping your employer from sending you to that “must attend” conference?  If you answered yes to either of these questions, apply for a MAHQ Professional Enhancement Grant today! 

This grant provides financial assistance to MAHQ members to obtain the Certified Professional in Healthcare Quality credential or attendance at a regional or national conference for members who already have this certification.  There are restrictions on how the monies can be used and details can be found on the MAHQ website.  What do you have to lose in checking it out?  Let MAHQ assist you in your 2017 professional development goals.

MAHQ will be accepting applications through September 30, 2017 and grants will be awarded during Health Care Quality Week in October 2017.   Go to for more information and to apply.

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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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