The ultimate goal of the Quality Management program in the Department of Psychiatry at Mass General is to ensure universal adherence to the quality and safety practices and guidelines that we adopt and to reduce adverse events over time, to the lowest achievable level, and to zero where possible.


The Division of Quality Management within the Department of Psychiatry serves as the focal point for its quality management activities. Janet Wozniak, MD, serves as the Director of Quality Management. She chairs a multidisciplinary, departmental quality assurance committee made up of voluntary faculty, including five psychiatrists, three psychologists and two nurses.

The director of the division performs a fairly recently expanded role, combining both the historical quality assurance (QA) function with quality improvement (QI) activities. Similar “quality chairs” have been established at the departmental level throughout Mass General to meet growing demands for quality from payers, patients, and regulatory agencies.

Scope of Services

There are four major activities which fall under the domain of Departmental Quality:

  • Quality Assurance: This includes both retrospective review of adverse events and prospective planning to prevent these events. The majority of adverse events are brought to attention through electronic reporting, as well as security logs, patient complaints and malpractice complaints. The committee uses a Root Cause Analysis (RCA) process to identify modifiable system-level causes of poor outcomes. The results of the RCAs are communicated to the Department of Psychiatry’s leadership and to the Clinical Council for discussion of implementation of change.
  • Internal Quality Improvement: The Department of Psychiatry is engaged in a number of “bottom-up” quality improvement efforts focused on process change. Two large-scale examples include efforts to improve the rate of screening for problem alcohol use and efforts to improve adherence to national guidelines for management of metabolic syndrome. These initiatives are implemented through the outpatient clinic. These efforts have been guided by the “shared baseline” principle developed by Dr. Brent James at Intermountain Healthcare in Salt Lake City, UT, and the “Breakthrough Series Model” for change management developed by the Institute for Healthcare Improvement in Cambridge, MA.
  • Clinician Credentialing/Privileging: The Division works together with others in the Department of Psychiatry to review all clinicians seeking clinical appointments in the department. This process includes new efforts to establish objective provider performance evaluations (OPPE) and focused provider performance evaluations (FPPE) as recently mandated by The Joint Commission. Because a large percentage of clinicians who hold clinical appointments in psychiatry at Mass General supervise or teach rather than actively caring for patients, development of OPPEs required novel use of web-based assessment technology, developed in concert with the Department’s Division of Postgraduate Medical Education.
  • Meeting External Quality Mandates: A final aspect of Department’s quality efforts includes meeting the mandates for quality measurement imposed by a growing number of payers and regulators. Requirements include the implementation and reporting of aggregate outcomes measures to guide outpatient care, and the recent participation in the Joint Commission’s new Hospital-based Inpatient Psychiatric Services (HBIPS) measures set. In this effort, we have worked closely with psychometric experts at Mass General and throughout the Mass General Brigham system to guide the use of appropriate instruments. Of particular note is the development of the widely used Schwartz Outcome Scale (SOS) by Mark Blais, PsyD, to assess self-reported levels of psychological distress.