April 27, 2001

Last fall, MGH leadership announced the establishment of a new hospitalwide program to help coordinate the many quality and safety efforts at the MGH. The new Quality and Safety Program was launched to incorporate several initiatives already in practice and provide an enhanced management structure. A collaborative effort between the MGH and the Massachusetts General Physicians Organization (MGPO), the program focuses on providing leadership and support to quality-related endeavors, as well as improved communications among these efforts.

The responsibility for the Quality and Safety Program has risen to the top of the MGH organizational chart with the establishment of a trustee-level Quality of Care Committee. Reporting to this committee is a new Quality Oversight Committee, which is chaired by Brit Nicholson, MD, chief medical officer, and Jeanette Ives Erickson, RN, MS, senior vice president for Patient Care Services and chief nurse.

The working arm of this new structure is the Office of Quality and Safety (OQS), which serves as a central resource for all related hospital initiatives and issues. The OQS staff will work in tandem with such committees as the Patient Care Assessment Committee, Medical Policy Committee and Safety Committee, as well as quality-based department programs.

The OQS is led by Joan Fitzmaurice, RN, PhD, of Patient Care Services, and Cy Hopkins, MD, of the Department of Medicine, who are the directors of the office, along with Elizabeth Mort, MD, of the Decision Support Unit, who is the co-director. Honor Keegan, RN, Tricia Lemon, RN, and Linda Devaux are support staff of the OQS.

Since the inauguration of the OQS in January, the office has set goals and is working on several new initiatives. The goals of the OQS are to integrate and coordinate all quality improvement and patient safety activities; ensure that processes and policies are in place to optimize safety measures; monitor and analyze hospital performance and progress; and provide training for clinical and support staff to assist in these activities.

"Quality embraces every aspect of this institution — from our operational efficiency to our bedside care," says Hopkins
(at right). "It is a monumental effort to coordinate all of the important work being done throughout the hospital and the MGPO to ensure the highest quality of patient care and to create an environment of thoughtful safety practices. The work of this office will help ensure that commitment to quality and safety is part of the very fabric of this hospital."

The OQS staff have already begun work to strengthen the current structure of quality review systems, develop a new nonretaliation incident reporting policy and facilitate a better tracking mechanism for incident report follow-up. The OQS also is developing a hospitalwide quality assessment tool (also called a "quality dashboard") and plans to coordinate reporting needs regarding quality improvement efforts.

"The quality of an organization involves more than just doing the right thing; it also means evaluating whether we are doing the right thing well," says Fitzmaurice (above left). "Through systematically evaluating our effectiveness, our overall safety, our efficiency and continuity, this office can improve the flow of communication throughout the hospital about how well we truly are doing."

Mort (at right) adds that focusing on the quality of hospital services is nothing new to the MGH. "The MGH has long been committed to providing a high standard of care and to improving the quality and safety of its services," she says. "For many years, the hospital has had programs and committees in place to evaluate effectiveness. The establishment of this office will help refocus our efforts in a coordinated way, and is one more milestone in a long history of living up to the highest standards of excellence in patient care."

For more information about the OQS, call (617) 726-9282.