15 years

Afternoon Forum: Celebrating Patient Safety Innovations

Paula Griswold
Massachusetts Coalition for the Prevention of Medical Errors


Susan Abookire, MD, MPH
Mount Auburn Hospital

Introduction of Panelists

Panel 1: Increasing Reliability of Processes

Alison Holliday, MPH
Terry O’Malley, MD
Partners Healthcare System

"The One Trick Pony Rides Again"

Dolores D. Suslak, MSN, CIC
Judy Tarselli, RN
Massachusetts General Hospital

The MGH Hand Hygiene Program
"90/90" and Beyond

Louise Weed, MS
David Osler, MD MPH
Cambridge Health Alliance

Follow-up on Abnormal Cancer Screenings: Creating a Systemwide, EMR-based Solution to Improve Patient Safety and Reduce Medical Errors

Panel 2: Cross Organizational Strategies for Prevention of Medical Errors

Rebecca Elkins, RN

Reducing and Preventing Healthcare Acquired Conditions in MA Nursing Homes

Laurie Herndon, MSN, GNP-BC
Mass Senior Care Foundation

Reducing Antipsychotics In Massachusetts Nursing Homes Using the OASIS Curriculum

Patricia Noga, PhD, RN, MBA, MEA-BC
Massachusetts Hospital Association

Reducing Preventable Readmissions and HAIs: The SPIA Approach

Tracy Gay, MHSA, JD
Board of Registration in Medicine

Sharing Lessons Learned

Panel 3: Communication, Public Trust and Culture of Patient Safety

Winifred Tobin
Medically Induced Trauma
Support Services (MITSS)

Melinda Van Niel, MBA
Beth Israel Deaconess
Medical Center

MITSS: The Patient Experience Following Medical Harm

Kim Munto RN, BSN
Milford Regional Medical Center

Second Victim

Lela Holden, PhD, RN
Massachusetts General Hospital

Disruptive Behavior Among Staff: Now What Do We Do?

Beverly Loudin, MD, MPH
Ailish Wilkie, MS, CPHQ

Atrius Health

Safety Event Reporting in the Ambulatory Setting: A Story of Success


Susan Abookire, MD, MPH
Mount Auburn Hospital

Summary of key themes

Afternoon Forum Presenter Biographies


Susan Abookire, BSEE, MD, MP, CPHIMS
Chair of the Department of Quality and Patient Safety
Mount Auburn Hospital

Susan Abookire, BSEE, MD, MP, CPHIMS, is the Chair of the Department of Quality and Patient Safety at Mount Auburn Hospital, a Harvard Teaching Hospital in Cambridge, Massachusetts. Dr. Abookire began her career as an electrical engineer in aviation systems designing and implementing flight management systems in the commercial aviation industry for a decade prior to her medical training. During that time, she served as design engineer for commercial aviation safety ground proximity warning systems, project manager for Boeing 757/767 flight management systems, and oversaw design of hardware and software systems as well as human factors design in cockpit warning systems.

A graduate of Harvard Medical School, Dr. Abookire completed residency at Brigham and Women’s Hospital, and then practiced and taught Internal Medicine full time at the Brigham and Women’s Hospital before devoting herself to leading patient safety and quality initiatives. Dr. Abookire received a Masters in Public Health from the Harvard School of Public Health in 1999, focusing on Clinical Effectiveness and Patient Safety. Dr. Abookire has taught and lectured nationally and internationally on topics including health care technology in clinical practice, human factors, adverse event reporting systems, disclosure and apology, and applying lessons from aviation safety to healthcare. She currently serves on the Clinical Advisory Board of Elsevier, and is Vice President of the Board of Directors for the Massachusetts Coalition for the Prevention of Medical Errors. She recently completed the Fellowship in Medical Education at Mount Auburn Hospital. Dr. Abookire is the Curriculum Director for the newly established Harvard Medical School Fellowship in Quality and Patient Safety, as well as the co-founder and President of the Society of Physician Quality Officers.

Presenters (in order alphabetical order):

Rebecca Elkins, RN, BSN, NHA
Program Manager for Patient Safety

Rebecca Elkins is a bachelors-prepared registered nurse and current Program Manager for Patient Safety at Masspro. Ms. Elkins joined the Masspro team in 2009 as a Performance Improvement Advisor assisting Massachusetts nursing facilities. Prior to joining the Masspro team, Ms. Elkins worked in the long term care/skilled nursing facility setting for over 14 years. Her long term care experience includes appointments as a Nursing Home Administrator/Executive Director and Quality Assurance/Safety Officer in addition to other management and supervisory roles.

Tracy L. Gay, MHSA, JD
Quality and Patient Safety Division
Board of Registration in Medicine

Tracy L. Gay is the Director of the Quality and Patient Safety Division at the Board of Registration in Medicine. She was previously the Deputy Director for the Betsy Lehman Center for Patient Safety and Medical Error Reduction, where she worked to develop, evaluate, and disseminate best practices for patient safety and medical error reduction.

Tracy has worked in the field of health policy throughout her career at state, federal and international levels. Prior to joining the Betsy Lehman Center, she worked for the New England Healthcare Institute as the Director of Health Policy and with the National Health Service in England as a Quality Improvement Manager. Tracy has also worked as an attorney for the Office of Inspector General for the United States Department of Health and Human Services.

Ms. Gay holds a law degree and a master’s degree in health service administration. She began her career as a Registered Dietitian.

Lela Holden, PhD, RN, CPPS
Patient Safety Officer
Edward P. Lawrence Center for Quality and Safety
Massachusetts General Hospital

Dr. Lela Holden is the Patient Safety Officer at Massachusetts General Hospital in Boston. She oversees the team who evaluate more than 18,000 safety event reports a year, and she provides leadership to the institution's quality and safety initiatives. She has guided the introduction and execution of a model for restoring teamwork following disruptive behavior. Prior to this position, Dr. Holden served in various leadership positions in the U.S. Air Force and was part of the Department of Defense efforts related to teamwork training in healthcare. She retired from the Air Force in the rank of colonel. Her research and publications have focused on safety culture and teamwork in ambulatory care.

Alison Holliday, MPH
Project Manager
Partners Patient Safety
Partners Healthcare System

Alison Holliday is Project Manager for Partners Patient Safety where her primary focus is improving patient transitions. She received a Master of Public Health from the London School of Hygiene and Tropical Medicine after receiving her BA in Human Biology from Stanford University. Her publications have included research in obtaining optimal outcomes in diabetic care and comparative health care policy between the United States and France. Her interest in patient safety and population health care improvement evolved out of her experience as a project leader in diabetic care at Brigham and Women's Jen Center and as an assistant editor to Dr. Tom Lee and Dr. James Mongan in their publication of Chaos and Organization in Health Care.

Beverly Loudin, MD, MPH
Medical Director
Patient Safety and Risk Management, Atrius Health

Beverly Loudin, MD, MPH is the Medical Director for Patient Safety and Risk Management at Atrius Health. Prior to joining Atrius Health, Dr. Loudin was the Director of Patient Safety and Quality at North Shore Physicians Group where she received two “Partners in Excellence” awards for her work in redesigning primary care. Dr. Loudin designed and implemented a training program for the Medical Assistants at NSPG that was later adopted by the Commonwealth Fund and Qualis Health to train staff in their Safety Net Medical Home Initiative.

Dr. Loudin is a board-certified obstetrician-gynecologist who began her career at Mt. Auburn Hospital in 1989. Dr. Loudin transitioned into health care management when she joined Tufts Health Plan as a Medical Director in 1998. She left Tufts HP in 2005 to pursue a master’s degree from the Harvard School of Public Health.

Dr. Loudin is a graduate of the University of North Carolina at Chapel Hill and Boston University School of Medicine.

Kim M. Munto, RN, BSN
Director of Risk Management
Milford Regional Medical Center

Kim Munto is the Director of Risk Management at Milford Regional Medical Center. She received her Bachelor’s degree of Science in Nursing from Walsh University and is currently pursuing a Master’s degree in Health Care Administration at Framingham State University. In 2004 Kim moved to Boston from Canton, Ohio with her husband and children. Ms. Munto volunteers for Make A Wish and enjoys spending time with her family.

Patricia M. Noga, PhD, RN, MBA, NEA-BC
Vice President
Clinical Affairs
Massachusetts Hospital Association (MHA)

Patricia M. Noga leads a variety of clinical and health system-related programs which support Massachusetts hospitals in continually improving patient safety and quality of care. Currently, she is the leader in implementing the MHA’s Statewide Performance Improvement Agenda focusing on statewide initiatives to improve quality, improve efficiency, and improve safety. Dr. Noga also is the state leader in the implementation of the national quality improvement collaborative in Massachusetts hospitals, Partnership for Patients; in conjunction with the American Hospital Association’s Hospital Research and Educational Trust.

Dr. Noga received her Associate in Liberal Arts degree from Elmira College and her Bachelor of Science in Nursing degree from Skidmore College. She received her Master of Business Administration degree from Suffolk University and her doctoral degree in health policy from the University of Massachusetts.

Terrence A. O'Malley, MD
Medical Director Non-Acute Care Services
Partners Healthcare System

Terrence A. O’Malley is an internist/geriatrician, Medical Director of Non Acute Care Services at Partners and co-investigator of an Office of the National Coordinator for Health Information Technology (ONC) Challenge Grant to develop data sets for transitions of care, exchange them using electronic HIE and to measure the impact of their use on health services utilization. This project is called IMPACT (Improving Massachusetts Post-Acute Care Transfers).

Within Partners he spends half time in clinical practice, co-chair the Discharge Transitions project and sit on the Steering Committees for Palliative Care, Readmissions and Quality Measurement. Within the ONC Standards and Interoperability Framework he is one of the national leads on the Longitudinal Coordination of Care Work Group which is creating standards for transitions of care and exchange of care plans for inclusion in Meaningful Use Stage 3.

David Osler, MD MPH
Medical Director for Ambulatory Quality and Patient Safety
Cambridge Health Alliance

Following graduation from Tufts Medical School and Harvard School of Public Health, David Osler has been a practicing pediatrician for many years. David has developed interest and expertise in community health, process improvement, quality improvement and patient safety. While leading the Ambulatory network at Cambridge Health Alliance, Dr. Osler became the Medical Director for Ambulatory Risk Management and has been involved in projects sponsored by CRICO, "Closing the Loop on Referrals" and “Follow up on Abnormal Cancer Screenings". David is now the Medical Director for Ambulatory Quality and Patient Safety at Cambridge Health Alliance.

Dolores D. (Dee Dee) Suslak, MSN, CIC
Director, Infection Control Unit
Massachusetts General Hospital

Dee Dee Suslak, MSN, CIC Graduated in 1978 from Mary Hitchcock Memorial Hospital School of Nursing. She is a Graduate of Salem State University with a BSN in 1983 and a MSN in Adult Acute Care Nursing in 2007. She has worked in critical care, cardiology, nursing education and infection control/prevention. Her Masters research was a qualitative study that focused on nursing care of patients on long-term ventilator support. Ms. Suslak is currently a student at UMB in Adult Primary Care working towards a DNP. She is the newly hired Director of the Infection Control Unit at MGH. Her interests include prevention of HAI’s in ICU, post-surgical and other at risk populations, vaccination compliance and patient and staff education. She is a member of APIC and APIC New England.

Judy Tarselli, RN
Infection Control Unit
Massachusetts General Hospital

Judy Tarselli, RN has worked as a nurse for over 30 years in areas ranging from Critical Care to Pediatrics, in specialties ranging from Occupational Health to Nephrology, and in locations from Pennsylvania to the Middle East. Despite her varied background, she considers the greatest challenge of her career to be the one she faced as a member of the Infection Control Unit at the Massachusetts General Hospital: Achieving hospital-wide excellence in hand hygiene practice and compliance.

Winifred N. Tobin
Communications Director
Medically Induced Trauma Support Services (MITSS)

Winifred N. Tobin joined MITSS in the spring of 2003. Since that time, she has been responsible for strategic communications surrounding all of the organization's activities including annual event planning, web content, print media, social media, and community outreach efforts. Her areas of specific interest include emotional support for anyone involved in an adverse event; patient safety and quality; patient engagement; health literacy; and, safer healthcare for diverse populations. She co-authored Engaging Minorities in Safer Healthcare in 2011. Ms. Tobin has served on numerous committees representing the patient’s voice, and, in particular, that of the patient who has suffered medical harm. Currently, she serves as on the Consumer Advisory Group to the Massachusetts eHealth Collaborative and is a member of MACRMI. She holds a BSBA degree in marketing from the Sawyer School of Management at Suffolk University.

Melinda Van Niel, MBA
Project Manager
Beth Israel Deaconess Medical Center

Melinda B. Van Niel is a project manager at Beth Israel Deaconess Medical Center in the Center for Healthcare Delivery Science. Ms. Van Niel received her Bachelor of Arts degree from Harvard University in 2008 and her Master’s in Business Administration from Villanova University with a concentration in healthcare management in 2012. Ms. Van Niel is responsible for implementation of the Communication, Apology, and Resolution (CARe) approach to adverse events at BIDMC and at affiliated community hospitals BID-Needham and BID-Milton. She also manages the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI), which promotes the use of the CARe process throughout the Commonwealth.

Louise Weed, MS
Patient Safety Project Manager
Cambridge Health Alliance

Louise Weed received her BA from Tufts University and her MS in Health Policy and Management from the Harvard School of Public Health. After working in policy for several years, Louise transitioned into health care management with a focus on Quality Improvement and system sustainability. Ms. Weed was chosen to be an IHI student leader, and has worked in several Boston-area institutions on a diverse range of QI projects. Louise is currently a Patient Safety Project Manager at CHA.

Ailish M. Wilkie, MS, CPHQ
Senior Project Manager
Patient Safety and Risk Management
Atrius Health

Ailish has spent her entire career working in the patient safety field. After spending her early years in state government, she has spent the last ten years in the healthcare setting, expanding her work to include risk management and quality improvement. Ms. Wilkie joined Atrius Health in 2008 where she is a Senior Project Manager in the Department of Quality and Safety; she is responsible for facilitating organization wide patient safety and risk management activities and serves as the business administrator of the electronic safety event reporting system. Prior to joining Atrius Health, Ailish worked at Children’s Hospital Boston as a Senior Quality Improvement Consultant and at Brigham and Women’s Hospital where she served as a Patient Safety Manager and the Coordinator of Clinical Compliance.

Ailish Wilkie received both a Bachelor of Science and Master’s in Health Management degree from Northeastern University.