Partnerscenter of Expertise in Quality & Safety

PARTNERSCENTER OF EXPERTISE IN QUALITY & SAFETY

FOR PARTNERS RESIDENTS & FELLOWS

FACULTY CO-CHAIRS:
ALLEN KACHALIA, MD, JD
Associate Chief Quality Officer, BWH
/ Allen Kachalia, MD, JD, is an academic hospitalist at Brigham & Women’s Hospital in Boston, Massachusetts. He is an Associate Professor at HarvardMedicalSchool and the Harvard School of Public Health.
As a clinician, Allen regularly attends and teaches on the hospital wards with medical students and residents. Administratively, as a member of the hospital’s leadership team, Allen serves as the Associate Chief Quality Officer for BWH and also co-directs the Center for Clinical Excellence. In this role, Allen provides oversight for the hospital’s inpatient and ambulatory quality, safety, and performance improvement activities. Allen also has a law degree, and maintains research pursuits in legal issues in medicine, including malpractice system reform and disclosure, and how they relate to the quality and safety of medical care.
ELIZABETH MORT, MD, MPH
Sr. Vice President for Quality and Patient Safety and Chief Quality Officer for MGH & MGPO
/ Elizabeth Mort, MD, MPH is a practicing general internist with more than fifteen years of experience in clinical performance management and operational improvement activities in an AcademicMedicalCenter and Integrated Delivery System setting. Dr. Mort currently holds the titles of Senior Vice President of Quality and Patient Safety and Chief Quality Officer for MGH and MGPO. She also serves as Senior Medical Director at Partners HealthCare, Inc (PHS).
Dr. Mort has extensive experience in health care quality measurement, quality and safety improvement, managed care medical management strategies, pay for performance contracting and hospital operations. At MGH she oversees the Center for Quality & Safety and is responsible for high stakes quality and safety measurement and improvement work across a broad range of initiatives. In her current roles at PHS, she leads the care redesign efforts aimed at common episodic procedures and conditions. Dr. Mort also plays a lead role in contracting quality incentives, and is leading the quality measurement reporting for the public website at Partners.
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 Measures. Dr. Mort currently serves on the NQF Expert Panel for Patient Reported Outcome measures.
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 HarvardMedicalSchool. 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.
FACULTY PARTICIPANTS:

DAVID W. BATES, MD, MSc
Senior Vice President for Quality and Safety and Chief Quality Officer, Brigham and Women’s Hospital and Brigham and Women’s Physician Organization
/ David Westfall Bates, MD, MSc is an internationally renowned expert in patient safety, using information technology to improve care, quality of care, cost-effectiveness, and outcomes assessment in medical practice. He assumed his current position at BWH in 2011.
At a time when patient safety has become a key driver for focusing national attention on healthcare quality, Dr. Bates' work has not only shown the magnitude of the problem but also provided a blueprint for helping solve it. He led a seminal study on the epidemiology of drug-related injuries, demonstrating that the most effective way to prevent serious medication errors is to focus on improving the systems. He has also performed many studies on how computerized, evidence based guidelines can improve quality and efficiency. Dr. Bates has been recognized for several years by Modern Healthcare magazine as one of the “100 most powerful” individuals in US health care.
In addition to serving as a practicing general internist and chief of General Internal Medicine, Bates also is a professor of medicine at HarvardMedicalSchool and a professor of Health Policy and Management at the Harvard School of Public Health, where he co-directs the Program in Clinical Effectiveness. He also serves as medical director of Clinical and Quality Analysis for Partners HealthCare. He directs the Center for Patient Safety Research and Practice at BWH, and serves as external program lead for research in the World Health Organization’s Global Alliance for Patient Safety. He is the associate editor of the Journal of Patient Safety.
Bates is a graduate of StanfordUniversity and the Johns Hopkins School of Medicine. He began his fellowship in general internal medicine at BWH in 1988, and he received an MSc in Health Policy and Management from the Harvard School of Public Health in 1990.
JEFFREY B. COOPER, PhD
Director, Center for Medical Simulation
/ Dr. Cooper serves as Director of the Center for Medical Simulation. He is internationally renowned in the anesthesia community for his seminal contributions to the prevention of adverse events and patient injury and is considered a pioneer in the development of medical simulation. His studies of human error in medicine in the 1970s were among the first ever conducted. Cooper retired last April as the director of Biomedical Engineering of Partners HealthCare, having served in this role for 14 years. Dr. Cooper created the Anesthesia Patient Safety Foundation (APSF) in 1985. This was the first organization in the world that focused solely on patient safety. Some years later, research that APSF supported led Dr. Cooper to see the benefit of simulation training for patient safety. At the Center for Medical Simulation, his goal is to get people to be more self-reflective, to think more deeply about how they make mistakes, how accidents happen and how they can prevent them. By using simulated clinical situations for training on teamwork and managing emergencies, caregivers learn how to avoid crises and develop better teamwork skills. In addition to a broad focus in patient safety, simulation for teamwork and learning without putting patients at risk is his primary interest.
SONALI DESAI, MD, MPH

Associate Physician, Brigham and Women's Hospital; Instructor in Medicine, HarvardMedicalSchool

/ Dr. Desai’s contributions at Brigham & Women’s hospital cover clinical care, research, administrative, and teaching roles. Her clinical care responsibilities include attending on the inpatient Rheumatology consult service and the outpatient Rheumatology clinic. Dr. Desai conducts research on quality of care in the rheumatic diseases, particularly rheumatoid arthritis, with support from the AmericanCollege of Rheumatology's Physician Scientist Development Award. She focuses on utilizing health information technology to measure and improve upon quality of care. Dr. Desai has reported on using administrative and clinical data to develop a quality metric on pneumococcal vaccination for immunosuppressed rheumatology patients. A quality improvement project to increase vaccination among at-risk patients is underway at the BWH rheumatology practice and affiliated sites. Dr. Desai is leading a pilot project to use computer tablets in the outpatient rheumatology practice to collect data from rheumatoid arthritis patients on functional status, present this patient-data electronically to rheumatologists during the office visit, and integrate this data with the electronic medical record. Additionally, Dr. Desai was awarded a pilot grant to measure and improve the care for patients at-risk for and with osteoporosis at BWH using a multidisciplinary team involving rheumatology, endocrinology, radiology, orthopedic surgery and emergency medicine.
Dr. Desaiisalso the Director of Quality for the Department of Medicine, overseeing the development, measurement and improvement upon clinical quality metrics, and the Ambulatory Director for Patient Safety at the Center for Clinical Excellence,serving as the physician leader for development and implementation of patient safety initiatives at BWH. The short-term goals of the Ambulatory Safety Team are to enhance the patient safety culture and to create a robust process of closing the loop on safety reports.
Dr. Desai received her MD from BrownUniversity, and an MPH focused on quality improvement, medical informatics and health information technology from the Harvard School of Public Health.
JESSICA C. DUDLEY, MD
Chief Medical Officer, Brigham and Women’s Physician’s Organization
/ As Chief Medical Officer for the Brigham and Women’s Physician’s Organization, Dr. Dudley is responsible for overseeing the contracting efforts on behalf of the BWPO and leading the medical management team in developing and implementing programs designed to meet pay for performance targets related to efficiency and quality. Additional responsibilities include addressingphysician work-life issues and collaboration and development of physician leadership and volunteerism programs. Previously, as Associate Medical Director for Partners Community HealthCare, Inc. (PCHI), and Team Leader for the High Performance Medicine Trend Management Team, Dr. Dudley was responsible for developing and coordinating system wide approaches to address areas of increasing resource utilization. The targets included physician utilization of pharmaceuticals and high cost imaging tests. These efforts included collaboration from multiple institutions to develop and implement strategies to optimize appropriate utilization of these resources. For both pharmacy and radiology, this included use of electronic ordering platforms by physicians at the time of ordering, development and deployment of guidelines to support physician decision making, and feedback of practice patterns to physicians.
Previously, Dr. Dudley was Medical Director for Partners Human Resources. Dr. Dudley supported the Human Resources team in the development and management of the pharmacy benefit for Partners employees and their dependents including contracting and on-going formulary management. Dr. Dudley was also responsible for working with insurers and other vendors to develop and deploy disease management programs for employees. Prior to this position, Dr. Dudley had worked as Associate Medical Director and prior to that, Assistant Medical Director, for PCHI. In these roles, Dr. Dudley was responsible for providing clinical support for negotiating risk and pay for performance arrangements with local insurers on behalf of the PCHI Network. Dr. Dudley was also responsible for the development and on-going management of PCHI’s Pharmacy Management Program.
Dr. Dudley received her medical degree from HarvardMedicalSchool. She completed her internship and residency in Primary Care Internal Medicine at Brigham and Women’s Hospital in Boston, MA and is Board Certified in Internal Medicine.
TIMOTHY FERRIS, MD, MPH
Vice President, Population Health Management
/ Dr. Ferris is a practicing general internist and pediatrician and the medical director of the Mass General Physicians Organization. He also serves as vice president for Population Health Management at Partners, and is formally the Vice Chair for Quality for Partners Pediatrics and MassGeneralHospital for Children. He is a Senior Scientist in the Partners/MGH Institute for Health Policy and an Associate Professor of Medicine at HarvardMedicalSchool. His research has focused on the measurement and improvement of health care quality for adults and children, particularly focused on the roles of financing and health information technology.
In addition to quality improvement interventions, he has published studies on the effects of the organization and financing of care on the costs and quality of care, risk adjustment of quality measures, and disparities in health care. He has over 50 publications including those in journals such as the New England Journal of Medicine, JAMA, Pediatrics, and Health Affairs. Dr. Ferris has been leading efforts at Partners Healthcare to improve the care of patients with multiple chronic conditions with specific responsibility for design, oversight and evaluation of programs to improve quality and efficiency of care for high-risk patients such as those with heart failure.
Dr. Ferris has been a member of the Agency for Healthcare Research and Quality’s Health Care Quality and Effectiveness Research study section, has chaired two Technical Advisory Panels for the National Quality Forum, sits on the Quality and Safety subcommittee to the Board of the National Association of Children’s Hospitals and Related Institutions (NACHRI), and consulted to the World Health Organization.

TEJAL K. GANDHI, MD, MPH
Chief Quality and Safety Officer, Partners HealthCare
/ Dr. Gandhi is a board certified internist and Associate Professor of Medicine at HarvardMedicalSchool. She received her MD and MPH from HarvardMedicalSchool and the Harvard School of Public Health, and trained at DukeUniversityMedicalCenter. Her undergraduate training at CornellUniversity was in biochemistry.
Dr. Gandhi’s research interests focus on patient safety and reducing error using information systems. She won the 2009 John Eisenberg award for her contributions to understanding the epidemiology and possible prevention strategies for medical errors in the outpatient setting. Dr. Gandhi was the Executive Director of Quality and Safety at Brigham and Women’s Hospital for 10 years, and in that role, she worked to redesign systems to reduce medical errors and improve quality. Currently, Dr. Gandhi is Chief Quality and Safety Officer at Partners Healthcare. In this role, she is helping to lead the efforts to standardize and implement patient safety best practices across the system.
ATUL GAWANDE, MD, MPH
Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute
/ A surgeon and a writer, Atul Gawande is a staff member of Brigham and Women's Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. He received his BAS from Stanford University, MA (in politics, philosophy, and economics) from Oxford University, MD from HarvardMedicalSchool, and MPH from the Harvard School of Public Health. He served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. Since 1998, he has been a staff writer for the New Yorker magazine. In 2003, he completed his surgical residency at Brigham and Women's Hospital, Boston, and joined the faculty as a general and endocrine surgeon. He is also Associate Professor of Surgery at HarvardMedicalSchool, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWHCenter for Surgery and Public Health. He has published research studies in areas ranging from surgical technique, to US military care for the wounded, to error and performance in medicine. He is the director of the World Health Organization's Global Challenge for Safer Surgical Care.
In 2006, he received the MacArthur Award for his research and writing. His nonfiction writing has been selected to appear in the annual Best American Essays collection twice and in Best American Science Writing five of the last six years. His book COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. He is editor of THE BEST AMERICAN SCIENCE WRITING 2006. His most recent book, BETTER: A SURGEON'S NOTES ON PERFORMANCE was selected as one of Amazon.com's ten best books of 2007.

MICHAEL GUSTAFSON, MD, MBA
Chief Operating Officer, Brigham & Women’s FaulknerHospital
/ Dr. Michael Gustafson is Chief Operating Officer of Brigham & Women’s FaulknerHospital, Boston, MA. In his previous role as Senior Vice President, Clinical Excellence, BWH/Faulkner Hospitals, Dr. Gustafson directed the Center for Clinical Excellence, which was created in 2001 to guide theinstitution's strategies for clinical performance measurement, analysis, improvement, and planning across such dimensions of care as service excellence, operational efficiency, quality, and patient safety. He also served as a principal quality liaison and representative for the institution within Partners HealthCare System and with the Dana Farber Cancer Institute. He was the Executive Sponsor for a hospital-wide Balanced Scorecard reporting and management system at BWH, one of the first of its kind to be implemented in a U.S. academic medical center. In 2005, he also assumed direct operational responsibility for the institution’s Pharmacy and Pathology Services, with oversight for approximately 800 FTE's and annual operating expenses exceeding $140 million.
Dr. Gustafson serves as an Assistant Professor in the Department of Surgery at HarvardMedicalSchool, with research interests including risk-adjusted surgical outcomes, the application ofhuman factors and systems thinking to patient safety, and effective structures and methods to drive change within complex healthcare settings. He completed his MD degree at West VirginiaUniversity, his General Surgery residency at Brigham & Women's Hospital, and a 3-year NIH funded surgical research fellowship at Massachusetts GeneralHospital. He later went on to become one of the first surgeonsto ever receive an MBA degree from HarvardBusinessSchool, where he graduated in 1999 with honors.
LELA M. HOLDEN, PhD, RN

Patient Safety Officer for Massachusetts GeneralHospital

/ Lela Holden was named the first Patient Safety Officer for Massachusetts GeneralHospital, Boston, Massachusetts in July 2008. In that position she oversees the staff and processes for safety event reporting, which numbered more than 15,000 in 2011. She also oversees the root causes analyses for major investigations and the reporting of events to the Massachusetts Department of Public Health and the Board of Registration in Medicine. Dr. Holden has developed and executed a model for team restoration following disruptive interactions among staff members. She has lectured both nationally and internationally on patient safety.
Dr. Holden holds a Master’s degree in psychology from the University of Santo Tomas in the Philippines, a Master’s degree in nursing from the University of California at San Francisco, and a PhD in nursing administration with a focus in patient safety from the UniformedServicesUniversity of the Health Sciences. Her additional credentials include certification in legislative affairs, advanced nurse executive certification, Certified Professional in Healthcare Quality (CPHQ), and Certified Professional in Patient Safety (CPPS). Her areas of research and peer-reviewed publications include the dimensions of patient safety in ambulatory care facilities and the topic of complex adaptive systems. Dr. Holden was on the board as part of the National Patient Safety Foundation to develop the first national certification in patient safety and continues as part of the expert panel for its ongoing oversight.