Massachusetts General Hospital
Edward P. Lawrence Center for Quality and Safety
55 Fruit Street, Bulfinch 2
Boston, MA 02114
Since 1811, Massachusetts General Hospital (MGH) has been committed to delivering standard-setting medical care. Throughout the decades, the hospital
has had a consistent commitment to advancing that care through pioneering research and educating future health care professionals. The third oldest general
hospital in the United States and the oldest and largest hospital in New England, Mass General continues its tradition of excellence today. The hospital
is consistently ranked among the top five hospitals in the nation by U.S. News & World Report, which currently ranks Mass General as first in the metro
Boston area and second in the U.S.
The MGH includes a 907-bed medical center, located in the heart of Boston, which offers sophisticated diagnostic and therapeutic care in virtually every
specialty and subspecialty of medicine and surgery. It also has long been a leader in successfully bridging innovative science with state-of-the-art clinical
medicine. With an annual research budget of nearly $550 million, MGH conducts the largest hospital-based research program in the United States - a program
that spans more than 20 clinical departments and centers across the hospital. MGH is also the original and largest teaching hospital of Harvard Medical
School, where nearly all staff physicians serve on the faculty.
The MGH Department of Patient Safety and Quality is located in downtown Boston at the Edward P. Lawrence Center for Quality and Safety (CQS) on the main
hospital campus. Established in 2007, the CQS supports the MGH and Massachusetts General Physicians Organization’s (MGPO) goal of creating the highest
quality, safest care environment for our patients and staff. Employing a multidisciplinary team of physicians, nurses, analysts, researchers, consultants
and informatics professionals, the CQS serves as an institution-wide resource to further the MGH’s aspiration of national leadership in quality and safety.
Fellows may participate in the activities of the CQS as it carries out its work through three key activities:
- Safety –Within CQS, a team of led by the Sr. Director of Patient Safety, triages, and if appropriate, investigates safety events entered into the reporting system.
It works extensively with the hospital’s Quality and Patient Safety Committee, chaired by Cyrus Hopkins, MD, and supports the review and reporting of cases to the Board of
Registration in Medicine, and other external regulatory and accrediting bodies.
- Quality Management –Led by Syrene Reilly, MBA, oversees quality data measurement and analysis. The group develops and reports on quality measures internally and externally.
It is staffed by data analysts and quality measurement nurses.
- Process Improvement – Process Improvement is a major MGH/MGPO initiative intended to advance ongoing initiatives around quality and safety, patient experience, and efficiency.
The MGH/MGH brings a broad range of tools—LEAN, WorkOut, Rapid Cycle Testing, etc—to bear on projects that advance these strategic priorities.
Led by Mary Cramer, Sr. Director of Process Improvement, the program is responsible for training project facilitators, selecting appropriate projects, and tracking the
results of those projects.
Data for quality improvement resides in a variety of clinical and non-clinical systems at the hospital, and it requires the expertise of IT and informatics
professionals to make this data actionable. Led by Henry Chueh, MD, Chief Medical Information Officer, the Applied Informatics group develops and manages
the information systems needed to support quality measurement and reporting activities, including the incident reporting system and quality and safety
dashboard. The work is carried out in close collaboration with the MGH Lab of Computer Sciences.
CQS Leadership Team:
The field of quality and safety continues to grow and evolve, providing CQS with a unique opportunity to influence and define the direction of quality
measurement and improvement. Under the leadership of David Shahian, MD, the CQS Research team undertakes numerous research projects that rigorously evaluate
existing quality and safety measurement and improvement mechanisms, and illuminate new areas of exploration and study for the field.
- Elizabeth A. Mort, MD, MPH - Senior Vice President for Quality and Safety, Chief Quality Officer, MGH
- John B. Belknap, MPA - Chief Compliance Officer
- Henry C. Chueh, MD, MS - Chief Medical Information Officer
- Mary O. Cramer, MBA - Sr. Director of Process Improvement
- Cyrus C. Hopkins, MD - Medical Director, Patient Safety; Chair, Quality and Patient Safety Committee (QPSC)
- Syrene Reilly, MBA – Sr. Director of Quality Management
- David M. Shahian, MD - Vice President
- Daniel Yagoda, MPH - Administrative Director
Dr. Mort is a practicing general internist with more than a decade of experience in clinical performance management and operational improvement activities
in an Academic Medical Center and Integrated Delivery System setting. She has extensive experience in health care quality measurement, quality and safety
improvement, managed care medical management strategies, pay for performance contracting and hospital operations. In her current roles at Partners HealthCare
(PHS), she leads the condition specific care redesign effort, plays a lead role in contracting quality incentives, and is leading the transparency work.
At MGH she leads high stakes quality and safety measurement an improvement work across a broad range of initiatives.
Dr. Mort was on the AHA panel on Healthcare Acquired Conditions in 2011. She co-chairs the Mass Medical Society’s committee on the quality of medical
practice. Dr. Mort has been a member of the NCQA’s Women’s Health Measurement Advisory Panel. She was a member of the National Quality Forums Technical
Advisory Panel for the development of hypertension measures. She has served as a member of the Agency for Healthcare Research and Quality Composite Measures
Workgroup inpatient quality indicator sub-workgroup. She has served on the NQF Steering Committee for Additional Priorities for Acute Hospital Quality
Dr. Mort completed her residency in primary care internal medicine at MGH in 1986 followed by two fellowship years at the Department of Health Care Policy
at Harvard Medical School. She also completed a Masters in Public Health at the University of Michigan in 1982, which focused on Health Planning and Administration
and Population Planning.