Matthew Hutter, MD, MPH, Shaun Sutcliffe, RN, BSN, Kathy Swierzewski, RN, and Lynn Devaney, RN, BSN
Members of the Codman Center lead quality and safety initiatives to improve patient care at Massachusetts General Hospital. Pictured (left to right): Matthew Hutter, MD, MPH, Shaun Sutcliffe, RN, BSN, Kathy Swierzewski, RN, and Lynn Devaney, RN, BSN.

Leading Quality and Safety in a Dynamic Health Care Environment

As the current health care landscape rapidly evolves in response to social, economic and political pressures, the need for comprehensive data on quality and safety measures is increasing. These data help identify ways to improve patient care, establish benchmarks to assess the performance of treatment options and inform policy discussion and development.

In addition to collecting data to support national health care assessment efforts, the Codman Center for Clinical Effectiveness in Surgery leads a number of quality and safety initiatives within the Department of Surgery to improve patient care and safety at Massachusetts General Hospital. A formal structure has been established within the department to centralize and share resources to improve quality and safety. Each of the 12 divisions within the Department of Surgery has a dedicated quality and safety director who works in conjunction with the center and the department’s quality and safety leadership team to review the division’s quality data regularly. Through this assessment, department leaders continuously improve patient care by sharing best practices, developing and implementing department-wide and division-based improvement programs and analyzing trends in surgical quality and safety data.

Learn more about quality and safety at Mass General

Current Projects

Current projects led by the Codman Center include:

Quality Improvement

  • Improving patient access and experience of care, including the implementation of Service Excellence Standards which outline specific actions that hospital staff should take to ensure a positive patient experience
  • Creating more effective handoffs and communication among caregivers and between caregivers and patients
  • Developing and implementing appropriateness criteria via PrOE, an electronic platform that provides feedback to providers and patients regarding relative risks and benefits of certain procedures
  • Redesigning care delivery to improve hospital efficiency and response time to patients
  • Reducing length of stay and unplanned readmissions
  • Preventing infections


  • Promoting a blame-free culture of safety at all levels  
  • Investigating and following up on safety reports
  • Implementing the Department of Surgery Communication and Safety Guidelines, which outline the department’s standards for professional conduct and communication as it relates to interactions with colleagues, referring physicians, patients and families

Reporting and Data Management

  • Publishing a comprehensive annual quality and safety report
  • Maintaining a quarterly dashboard  to monitor progress of key initiatives
  • Generating quality and safety reports on individual physicians
  • Participating in national databases to inform on quality and safety improvement and research
  • Developing a quality and safety outcomes website to provide public reporting on Mass General’s surgical outcomes

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