Meet Our Quality and Safety Team

Directors

Jennifer Beloff, RN, MSN, APN
Jennifer Beloff is the Executive Director of Quality in the Department of Quality and Safety at Brigham and Women’s Hospital. Jennifer is a nurse practitioner with over 17 years of healthcare quality and patient safety experience. She joined BWH in August 2008 and is responsible for the operational management, strategic planning, and performance on all commercial, state, and federally funded pay for reporting (P4R) and pay for performance (P4P) programs, as well as the management and performance improvement efforts associated with a growing body of publicly reported metrics included in external quality reporting organizations, local/state government agencies, and medical boards and associations. Additionally, Jennifer also oversees the strategic planning, goal setting, and management of the Clinical Pathways and the Clinical Documentation Improvement programs at BWH. Prior to joining the hospital, Jennifer worked at Valley Hospital in Ridgewood, NJ (just outside of New York City) as a nurse, nurse practitioner, and clinical quality specialist.

Sonali Desai, MD, MPH
Dr. Sonali Desai is the Medical Director of Ambulatory Patient Safety at Brigham and Women’s Hospital, the Medical Director of Quality for the Department of Medicine, and is a practicing rheumatologist. Dr. Desai conducts research on improving the quality of care and patient safety with a focus on the ambulatory setting. Dr. Desai is also an Assistant Professor of Medicine at Harvard Medical School and served as a Program Director (2015-2017) for an innovative global education, blended learning course titled Safety, Quality, Informatics, and Leadership. She is a native of Massachusetts and attended both college and medical school at Brown University in Rhode Island. She completed her internal medicine residency and Chief residency at Beth Israel Deaconess Medical Center in Boston, her rheumatology fellowship at BWH, and her MPH at the Harvard School of Public Health.

Kelly Doorley, RN, MS
Kelly Doorley is the Director of Clinical Compliance at Brigham and Women’s Hospital. She joined the hospital in November 2010 and is responsible for directing the hospital-wide efforts of all regulatory compliance and surveys including The Joint Commission and Centers for Medicare and Medicaid Services. She works closely with all levels of the organization to ensure Brigham and Women’s Hospital remains in compliance with state and federal rules and regulations including hospital licensure requirements. Prior to joining BWH, Kelly held varying positions across Partners Healthcare including staff nurse at Massachusetts General Hospital, Compliance Manager at Partners Healthcare Internal Audit, and most recently was the Director of Continual Readiness, Patient Safety, and Infection Prevention and Control at Brigham and Women’s Faulkner Hospital.

Adam C. Fields, MD
Dr. Adam Fields is a Fellow in the Harvard Medical School Fellowship in Patient Safety and Quality at Brigham and Women's Hospital. He focuses on both hospital-wide and surgery-specific quality and safety projects. His interests include disclosure of adverse events/malpractice, reduction of opioid prescriptions, and prevention of medical errors. Dr. Fields is clinically active as a General Surgery Resident at BWH. He received his undergraduate degree from Yale University and his medical degree from the Icahn School of Medicine at Mount Sinai.

Karen Fiumara, PharmD, BCPS, CPPS
Karen Fiumara is the Executive Director of Patient Safety in the Department of Quality and Safety at Brigham and Women’s Hospital. She joined Brigham and Women’s Hospital in August 2002 and is responsible for the strategic planning and direction of the BWH Safety program. Particular areas of focus include enhancing the culture of safety at BWH, proactive and reactive risk assessment, and ensuring compliance with National Patient Safety Goals. Karen graduated from Massachusetts College of Pharmacy and completed a pharmacy practice residency at BWH. Prior to joining the Department of Quality and Safety, Karen worked as the Medication Safety Officer and managed the Anticoagulation Management Service at Brigham and Women’s Hospital.

Mallika Mendu, MD, MBA
Dr. Mallika Mendu is a Medical Director for Quality and Safety at Brigham and Women's Hospital. Dr. Mendu is also a practicing nephrologist, following inpatients and outpatients with chronic kidney disease and end stage renal disease. In addition, she is the director for quality improvement for the Nephrology Division and part of the Partners Population Health Management Team.

She received her MD and MBA degrees from the Yale School of Medicine and Yale School of Management. During her internal medicine residency at Brigham and Women’s Hospital, she was involved in the Medicine Management Leadership Track and developed an interest in addressing system-level deficiencies in quality and care delivery by implementing innovative interventions. She pursued a nephrology fellowship at Brigham and Women’s Hospital and Massachusetts General Hospital, and conducted research related to quality improvement.

Dr. Mendu is currently involved in clinical research related to improving care delivery for patients with kidney disease, and has over 20 peer-reviewed publications related to this field. Within the Department of Quality and Safety, Dr. Mendu's responsibilities are focused on mortality review and collaborating with department quality leaders to address systems issues identified through mortality review.

Peter Najjar, MD
Dr. Peter Najjar is an Administrative Chief Resident in Surgery at BWH. He completed his HMS Fellowship in Patient Quality and Safety at BWH in 2016. In addition to hospital-wide quality and patient safety work, he focuses on improving surgical care through enhanced collaboration between the Department of Quality and Safety and the Department of Surgery. He attended the University of California, Davis, before completing his MD at the University of Chicago in 2011 and his MBA at Harvard Business School in 2016. His research focuses on improving the value of surgical care by increasing front-line clinical data feedback, improving cost measurement, reducing resource utilization, and improving care process reliability. Examples include the use of time-driven activity-based costing (TDABC), Enhanced Recovery after Surgery (ERAS) implementation, and system-wide venous thromboembolism (VTE) prevention.

Marc Pimentel, MD, MPH, CPPS
Dr. Marc Pimentel is a Medical Director for the Department of Quality and Safety and primarily works on the Hospital Acquired Conditions Reduction program for BWH. Following his anesthesiology residency at BWH, he completed the two-year HMS Fellowship in Patient Safety and Quality. He continues to practice as an attending anesthesiologist in the BWH operating rooms, while also serving as the Associate Clinical Director for Quality in the Department of Anesthesiology. Current projects include prevention of central line infections and catheter-associated urinary tract infections, and improving hand hygiene.

Hojjat Salmasian, MD, MPH, PhD
Dr. Hojjat Salmasian is the Program Director for Data Science and Evaluation at Brigham and Women’s Hospital and is also an Instructor of Medicine at Harvard Medical School (HMS). Hojjat leads our efforts on using advanced data science and informatics approaches to measure and improve quality, safety, and value of care delivered at Brigham and Women’s Hospital and affiliated hospitals and programs. In his academic role, Hojjat leads federally funded research projects focused on improving medication safety and reducing wrong-patient order entry. Hojjat received his medical and public health degrees from Tehran University of Medical Sciences, and his PhD in biomedical informatics from Columbia University. Prior to joining BWH and HMS, he held a similar role at NewYork-Presbyterian Hospital and Columbia University, leading a team of five advanced data scientists.

Karthik Sivashanker, MD, MPH, CPPS
Dr. Karthik Sivashanker is the Medical Director of Quality, Safety, and Equity at Brigham and Women's Hospital, a consultation-liaison trained psychiatrist at Justice Resource Institute, and a Clinical Scholar at the Institute for Healthcare Improvement. He joined Brigham Health in 2017 as an HMS fellow in Patient Safety and Quality. He transitioned to his new role in July of 2019 and is focused on advancing a culturally competent health care system capable of delivering the highest-quality and safest care available to every patient regardless of race, ethnicity, social class, culture, ability to pay, or language proficiency. He attended both college and medical school at Northwestern University in Illinois. He completed his psychiatry residency at NYP Weill Cornell in New York and a fellowship in consultation-liaison psychiatry at Brigham and Women's Hospital. He received his MPH at the Harvard School of Public Health. He is a former Fulbright Scholar and VA Under Secretary for Health Diffusion of Excellence Gold Fellow. He has published on topics including quality and safety, opioid use disorders, and mental health.

Scott Weiner, MD, MPH, FACEP, FAAEM
Dr. Scott Weiner is an Assistant Professor of Emergency Medicine at Harvard Medical School and an Attending Emergency Physician and Director of the Health Policy Research Translation Fellowship in the Department of Emergency Medicine at Brigham and Women’s Hospital in Boston. He is also the Director of B-CORE: The Brigham Comprehensive Opioid Response and Education Program, a hospital-wide, multi-disciplinary project with the goal of reducing opioid-related morbidity and mortality. Dr. Weiner completed his residency training at the Harvard-Affiliated Emergency Medicine Program at Beth Israel Deaconess Medical Center and MPH degree at Harvard School of Public Health. He is the President of the Massachusetts College of Emergency Physicians. His research focuses on technological innovations that improve the care of ED patients presenting with pain, including usage and optimization of online prescription drug monitoring programs (PDMPs), as well as improving access to naloxone, the life-saving opioid overdose reversal medication.

Paige Wickner, MD, MPH
Dr. Paige Wickner is a Medical Director for Quality and Safety at Brigham Health. She completed her medical school degree at Dartmouth Medical School, and internship at Brown’s Rhode Island Hospital. She then went on to complete her internal medicine training at Yale New Haven Hospital, where she stayed and completed an Allergy and Immunology Fellowship. During her Allergy and Immunology Fellowship she did a Masters in Public Health at Johns Hopkins Bloomberg School of Public Health. Dr. Wickner participates in research, clinical and quality projects examining drug allergy listings and their implications for patient quality and safety. She has an active grant focused on safety reporting of allergies during electronic medical record transitions. Dr. Wickner is presently focused on the patient experience at Brigham Health. Efforts include working with both inpatient and outpatient arenas and developing small and large scale projects and endeavors focused on improvement in the patient experience. Dr. Wickner also attends in the BWH inpatient medical service, serves as the Program Director for the Brigham Allergy and Immunology Fellowship Training Program, and sees inpatient and outpatient Allergy and Immunology patients at BWH.

Catherine (Kate) Ulbricht, PharmD, MBA, CPPS
Kate Ulbricht is the Director of Clinical and Academic Programs. She received her Bachelor of Science from the University of Connecticut, Doctor of Pharmacy from the Massachusetts College of Pharmacy and Health Sciences University, and Master of Business Administration from Northeastern University in Boston, MA. Kate has served as a Senior Attending Clinical Pharmacist at Massachusetts General Hospital and as an Assistant Professor at multiple universities since 1996. She founded an international research collaboration providing evidence-based decision support tools promoting patient safety. Her publications include hundreds of peer-reviewed scientific articles, book chapters, and texts. Kate helps propel our Joint Commission/National Patient Safety Goals, transparency, and educational efforts forward.

Casey McGrath, RN, MSN
Casey McGrath is the Director of Clinical Quality Programs. She earned her Bachelor of Science in Nursing and Master of Science in Nursing degrees from Endicott College. Prior to joining the Department of Quality and Safety in 2013, she worked as a staff nurse on the Intermediate Neuroscience Unit at Brigham and Women’s Hospital (BWH). Casey has worked closely with the Institute for Healthcare Improvement Open School as well as Sigma Theta Tau Chi Epsilon members on quality improvement projects. At BWH, Casey has led quality reporting and improvement efforts in surgery, heart failure, the emergency department, the NICU, nursing, and catheter associated urinary tract infection (CAUTI) prevention. In the spring of 2015, Casey successfully launched the Brigham Surgical Quality Redesign (BSQUARED) effort, a program that enabled multidisciplinary provider-led teams from the departments of surgery, anesthesia, and nursing to develop and implement projects that transformed front-line clinical expertise into hospital-level improvements in surgical quality and safety. Through this program Casey facilitated the expansion of the hospital’s Enhanced Recovery After Surgery (ERAS) protocol to multiple service lines. Currently, Casey oversees the growth and development of the Clinical Pathways Program and the Catheter-Associated Urinary Tract Infection (CAUTI) Prevention Task Force. Casey is also responsible for providing vision and direction of many clinical quality initiatives throughout BWH.

Safety Team

Karen Griswold, RN, MBA, CPPS, Lead Program Manager, Patient Safety, received her Bachelor of Nursing from the University of Vermont in Burlington, VT and Master of Business Administration from Simmons College in Boston, MA. Karen joined the Brigham as a part of the nursing department in 2000, and then the Department of Quality and Safety in December of 2007 as a Senior Consultant for Quality and Safety Programs. In her role, Karen leads Emergency Response and Rapid Response programs coordinating data collection, data reporting, and process improvement efforts, facilitates the Central Venous Catheter insertion safety group, as well as works with various other Patient Safety programs and initiatives.

Dr. Afrah Alkazemi has completed her PGY1 Pharmacy residency at BIDMC in 2019. She has a previous Bachelor of Pharmacy degree from Kuwait University, and a Master of Science Clinical Pharmacy, International Practice and Policy from University College London, United Kingdom. Afrah completed a PharmD at MCPHS University Boston in 2018. Dr. Alkazemi is passionate about delivering high-quality pharmacy services and she plans to pursue professional excellence in Critical Care. Outside of the hospital, Afrah enjoys experiencing new restaurants with friends and family and meeting new people.

Dr. Maryam Alobaidly is originally from Kuwait. She graduated from the Royal College of Surgeons in Ireland with BPharm and MSc degrees. She earned her Doctor of Pharmacy degree from MCPHS in Worcester, MA. Her professional interests include clinical trials, pharmacogenetics, solid organ transplant, and burns/plastics/ trauma critical care. Ultimately, she would like to practice as a board certified clinical pharmacy specialist at an academic medical center where she will have the opportunity to precept and mentor pharmacy students and residents. Maryam is currently a fellow at Brigham and Women’s Hospital in the Department of Quality and Safety, where she participates in various projects. She is also an adjunct professor for MCPHS in Boston. In her free time, she enjoys skydiving, rock climbing, bungee jumping, jet ski parachuting, wind surfing, and cooking and trying new food.

Tricia Hartley, MBA, MPH, Patient Safety Program Manager, received her Master of Business Administration with a focus in Healthcare Management and a Master of Public Health from Boston University. While pursuing these degrees she worked at Dana-Farber Cancer Institute on quality and process improvement projects focused on discharge procedures and protocols for bone marrow transplant patients. Tricia completed her Bachelor of Arts in Neuroscience and Sociology at Bowdoin College in Brunswick, Maine.

Roaa M. Khinkar, PharmD, PGY2 Quality and Safety Resident, earned her Doctor of Pharmacy from King Abdulaziz University (KAU) in Jeddah, Saudi Arabia. Prior to joining BWH Department of Quality and Safety, she was a PGY1 resident at Hallmark Health System in Medford, Massachusetts where she conducted Emergency Department Medication Reconciliation and Critical Care Services. Additionally, she successfully implemented a phenobarbital protocol for acute alcohol withdrawal syndromes. Roaa also serves as an adjunct professor for Massachusetts College of Pharmacy and Allied Health Sciences (MCPHS) where she facilitated pharmacotherapeutic seminar classes. Currently, Roaa helps mentor our clinical and academic rotation interns while participating in multiple projects involving quality, safety, compliance, and risk management initiatives across the healthcare system.

Eunji Michelle Ko, PharmD, Senior Safety Program Manager, received her Doctor of Pharmacy from Massachusetts College of Pharmacy and Health Sciences University in Boston, Massachusetts. Michelle served on Brigham and Women’s Hospital Emergency Department Medication Reconciliation Support Team helping to ensure patients were admitted to the hospital with Best Possible Medication Histories (BPMH). Prior to joining the Department of Quality and Safety as a Resident, she was a Clinical Content Consultant for Alosa Foundation in Boston, MA where she contributed to provider and patient educational materials. Michelle helps oversee clinical rotation students while participating on multiple projects involving quality, safety, and performance improvement initiatives across the healthcare system.

Daniel McAnally, MPH, Program Manager, joined the Department of Quality and Safety at Brigham and Women's Hospital in July 2019.  Prior to moving to Boston, Daniel worked as a transplantation coordinator in the Bone Marrow Transplantation Department at Mount Sinai Hospital in New York City.  He received his Master of Public Health (MPH) Degree from the Icahn School of Medicine at Mount Sinai.  Daniel's prior experiences include Program Analyst at the National Institutes of Health, Office of Clinical Research Training and Medical Education; Health Education Volunteer in Mali, West Africa with the United States Peace Corps; and patient transporter at the Bryn Mawr Rehabilitation Hospital in Pennsylvania.  Daniel is a certified yoga instructor and group fitness instructor.  When not in the office or on the yoga mat, Daniel enjoys spending time cycling, hiking, and playing cards.

Kristen Murray, MPH, Patient Safety Program Coordinator, earned her Master of Public Health with a concentration in Healthcare Management at Boston University and completed her Bachelor of Arts at Boston College where she majored in Psychology. Prior to coming to Brigham and Women's Hospital, she worked as a Program Assistant in the Center of Excellence in Women’s Health at Boston Medical Center.

Andrea Shellman, MHSA, CPPS, Lead Program Manager, Patient Safety, received her Bachelor of Arts in Biology and Psychology from Northwestern University in Evanston, IL and her Master of Health Service Administration from University of Michigan. In her role, she analyzes medical center safety trends, administers the patient safety culture survey, and facilitates other hospital-wide patient safety initiatives. Previously she worked at Kaiser Permanente, Los Angeles Medical Center as part of the transition team that facilitated opening a new hospital.

Sarah Williams, MPH, Patient Safety Project Manager, began her role as a Project Manager for the Department of Quality and Safety in June 2017 where she assists and oversees projects associated with patient safety. Prior to joining Brigham and Women’s Hospital, Sarah earned a Master of Public Health degree from Boston University where she concentrated in healthcare management. At Boston University School of Public Health, she pursued opportunities focused on quality and process improvement initiatives. Sarah completed her Bachelor of Art in Biology with a focus in Neuroscience at Assumption College in Worcester, MA.

Quality Team

Jodi Dalto, RN, MSN, Senior Program Manager, earned a Bachelor of Science in Nursing and a Master of Science in Nursing Administration from Northeastern University. For the past seven years, she has worked as a clinical instructor in Adult Health II for Northeastern University. Prior to joining the Department of Quality, Jodi started at Brigham and Women’s Hospital as a staff nurse in 2000, working in the Thoracic ICU, the Cardiac Intensive Care Unit (CCU), Angiography, and Cross-Sectional Interventional Radiology (CSIR). She has consistently demonstrated a passionate commitment to quality improvement initiatives. She led a project in the CCU to develop a comprehensive bedside reference tool for nurses. She also assisted in a quality improvement project in CSIR to improve first case on-time start times. She continues to work in collaboration on a research project for an Advanced Care Planning Toolkit for patients and families. In her role on the Quality team, Jodi focuses on quality measures related to ED throughput and the American Heart Association’s Program entitled Get With The Guidelines for Heart Failure.

Jo Ann David-Kasdan, RN, MS, SM, Lead Program Manager, is a Lead Program Manager in the Department of Quality and Safety at Brigham and Women’s Hospital. Prior to joining the Department of Quality and Safety in 2012 she most recently worked at Massachusetts General Hospital. She has had extensive clinical experience and has been involved in a wide range of projects including overall quality improvement in the care of patients with diabetes, heart failure and HIV, pediatric weight-based dosing, adverse events, and race and gender issues in kidney transplantation. At BWH, she focuses on hospital-wide quality and reporting initiatives and spends a significant amount of time reviewing and improving patient safety indicators.

Natalie Finn, Student Intern, is earning her Bachelor of Science in Nursing at Simmons College where she will be completing her program in 2020.

Kasey Moffat, RN, BSN, Senior Program Manager, earned her Bachelor of Science in Business Administration with a focus on Healthcare Management from the University of Connecticut. She worked as a Business Analyst at Children’s Hospital prior to earning her Bachelor of Science in Nursing from Simmons College. She worked as a staff nurse at Brigham and Women’s Hospital on the Neuroscience Intermediate Care Unit since 2014, where she was involved with quality initiatives related to fall prevention and served as a member of the Nursing Informatics committee and her unit-based practice council. In her role on the BWH Quality team, Kasey focuses on quality improvement initiatives related to inpatient venous thromboembolism (VTE) and inpatient influenza immunization.

Kelly Peters, MS, Senior Program Manager, earned a Bachelor of Science in Biology from Loyola University Chicago and a Master of Science in Exercise Science with a concentration in Public Health from Northeastern University. She completed her Master's clinical internship at Brigham and Women’s Hospital Department of Cardiology/Radiology. Prior to joining the Department of Quality and Safety, she worked as a Clinical Exercise Physiologist at Newton-Wellesley Hospital in the Department of Cardiology. As a member of the BWH Quality Team, Kelly previously focused on quality and reporting initiatives, including Emergency Department throughput, Get with the Guidelines Heart Failure, tobacco cessation, pain management, care coordination, and endoscopy. Currently, Kelly co-chairs the Brigham Health Sepsis Taskforce and focuses on reporting and quality improvement initiatives related to sepsis.

Robert Pierazek, RN, BSN, MBA, Senior Program Manager, joined the Department of Quality and Safety in January 2017. He earned his Bachelor of Science in Nursing from the Massachusetts General Hospital Institute for Health Professions and his Master of Business Administration from the University of Phoenix. Prior to joining the department, he worked for several years in the field of information technology in the banking industry. In October 2008, he began working in Care Coordination at BWH, and until recently, he worked as a registered nurse for an IV home infusion provider. Now with the Quality and Safety Department, Robert focuses primarily on maternity metrics.

Celene Wong, MHA, Program Manager, earned her Bachelor of Science in Exercise Science from the University of California, Davis and her Master of Healthcare Administration from Simmons College. Prior to joining the Department of Quality and Safety, she worked as a Project Manager in the Center for Patients and Families at BWH. In that role she supported multiple Patient Family Advisory Councils and worked with Patient Family Advisors to improve the patient experience. As part of the Quality team, Celene will support the Executive Director of Quality on numerous ongoing projects including the mortality review program and hospital performance ranking.

Clinical Compliance Team

Kelly Doorley, RN, MS, Director of Clinical Compliance, joined the hospital in November 2010 and is responsible for directing the hospital-wide efforts of all regulatory compliance and surveys including The Joint Commission and Centers for Medicare and Medicaid Services. She works closely with all levels of the organization to ensure Brigham and Women’s Hospital remains in compliance with state and federal rules and regulations including hospital licensure requirements. Prior to joining BWH, Kelly held varying positions across Partners Healthcare including staff nurse at Massachusetts General Hospital, Compliance Manager at Partners Healthcare Internal Audit, and most recently was the Director of Continual Readiness, Patient Safety, and Infection Prevention and Control at Brigham and Women’s Faulkner Hospital.

Lauren Mazzone, MBA, Clinical Compliance Program Manager, received her Bachelor of Science in Health Policy and Management from Providence College and her Master of Business Administration from Babson College. Lauren joined the Clinical Compliance team at Brigham and Women’s Hospital in 2013. In her current role, she contributes to maintaining organizational readiness, supports regulatory compliance surveys, and manages the hospital policy system.

DonnaMarie Maguire, RN, MSN, Clinical Compliance Senior Consultant, supports various hospital programs with addressing accreditation and related regulatory requirements with quality assurance performance improvement management for special projects. She received her BSN from Salve Regina University and joined BWH nursing in 1982. As well as inpatient nursing, she was the hospital ASPEN certified nutrition support nurse for inpatients and developed a patient home parenteral and enteral nutrition program. Research includes central venous catheter infection assessment and feeding glutamine to neonates. She also established the BWH needle safety program, and during her MSN in family education at UMass Boston she presented her research work on the impact of swabbable needleless systems to decrease needlesticks for healthcare workers.

Clinical Documentation Improvement Team

Deb Jones, MSN, RN, CCDS, Director of Clinical Documentation Improvement joined Brigham and Women's Hospital's CDI Team in January, 2015, and became Program Director in October, 2017. As Director of the CDI Program, Deb collaborates with Quality Professionals, Clinical Teams, Finance, and Coding to ensure the accuracy and integrity of patient medical records. Much of Deb’s previous work experience has been in the fields of Case Management and Utilization Review. Prior to joining the BWH CDI team, Deb served as the Team Leader of the Utilization Review Department at Geisinger Medical Center in Danville, Pennsylvania, where she was first introduced to CDI.

Cheryl Codner, RN, BSN, MPH-c, CCDS, Team Leader, joined the Brigham and Women's Hospital's CDI program in April, 2015, with 8 years of CDI experience and over 20 years of clinical experience in vascular surgery, medical surgical, and oncology nursing. As a member of the CDI team, Cheryl has been a member of the Coding Complications Committee and she is presently working with the team to develop and implement BH’s first Clinical Validation Appeals Program. Cheryl received a Bachelor of Science in Nursing from Rivier University in Nashua, New Hampshire, and is currently enrolled in their Master of Public Health program. She anticipates completion in 2020. Cheryl lives in Billerica with her husband, Bill, and their two daughters, Bridget and Lauren. Cheryl has traveled to Haiti and Jamaica pursuing her passion for service. Her next adventure is to begin working with Horizons for Homeless Children in August 2018.

Mary Lou Finn, RN, BSN, Clinical Documentation Improvement Specialist, joined Brigham and Women's Hospital's CDI Department in July, 2018, after a short stay with the Faulkner Hospital CDI staff. Mary Lou has extensive experience in CDI working at Steward Norwood Hospital since 2012. Prior to that, Mary Lou worked as a Case Manager for eight years. Mary Lou has 38 years of nursing experience in a wide variety of acute care, long term care, and community settings. She received a Bachelor of Science in Nursing from Framingham State University and attended St. Elizabeth’s Hospital School of Nursing. Mary Lou lives in Franklin with her husband, Ben. They have three adult children and recently became grandparents to a beautiful baby girl named Reese!

Danielle M. Forni, RN, BSN, CCRP, Clinical Documentation Improvement Specialist, earned her Bachelor of Science in Nursing from the University of Massachusetts, Dartmouth. Danielle began her nursing career in August, 1999, as a staff RN on a medical-surgical telemetry unit at Good Samaritan Medical Center in Brockton, MA. She joined Brigham and Women's Hospital in October, 2000, and worked as a staff RN on both the Thoracic Surgery Intermediate Care Unit and the Hematology-Oncology/BMT Unit. Danielle left BWH in August, 2008, to pursue an opportunity in clinical research as a CEC Clinical Reviewer at Harvard Clinical Research Institute in Boston, MA. In August, 2013, Danielle returned to Brigham and Women's Hospital and worked within the TIMI Study Group as a Senior CEC Medical Reviewer and subsequently as the CEC Manager of Medical Review. She joined the BWH CDI team in January, 2019, and is thrilled to have joined such an exemplary team of nursing professionals.

Doris Herrick, RN, BSN, CDSC, Clinical Documentation Improvement Specialist, joined the CDI department at Brigham and Women’s Hospital in January, 2018. She earned her Diploma in Nursing from St. Elizabeth’s Hospital School of Nursing and Bachelor of Science in Nursing degree from the University of Massachusetts, Boston. She has been working in Clinical Documentation since 2015. Her responsibilities include reviewing inpatient medical records to access and procure accurate and complete documentation of the patient’s diagnosis and procedures to accurately reflect quality of care, severity of illness and risk of mortality to support correct coding and quality initiatives. Prior to joining the CDI department, she worked in Case Management/Utilization Review for 15 years. Some of the other positions she has held in her 30 years in healthcare include Clinical Nurse Liaison, Travel Nurse, and Staff/Float Nurse.

Cindy Labins, RN, MSN, CCDS, Clinical Documentation Improvement Specialist, has over 25 years of both clinical and nursing leadership experience. She initially joined Brigham and Women’s Hospital in February, 1997, as a critical care staff nurse. Although she has left the Brigham several times to pursue other nursing opportunities, she returned to the Brigham and Women’s Hospital in May, 2017, in her current position. In this role, Cindy works to bridge the gap between provider documentation and coding through education and communication. Cindy supports providers to document all patient conditions and procedures in a language that coders can capture, to reflect the patient’s accurate severity of illness and risk of mortality. Cindy is currently working with her CDI colleagues on an initiative to ensure 100% of all nutrition consults and diagnoses of malnutrition are captured by the provider documentation.

Alisa Lundstrom, RN, BSN, CCDS, Clinical Documentation Improvement Specialist, joined the CDI team in January, 2017. She earned her Bachelor of Science in Nursing from Salem State University, and has been a nurse for 21 years, with combined experience in long-term care, Asthma/Allergy Specialty, and Intermediate Care Surgical Specialties. Six years of her experience was at the Brigham as a Staff Nurse on the Surgical/Intermediate Care/Burn Trauma/Renal Transplant Unit. She has been working as a clinical documentation specialist since 2013 and earned her Certified Clinical Documentation Specialist designation in October, 2017. Attending conferences as well as taking part in special projects are enjoyable to her. This year she has been involved with orienting new CDI Staff members to the program. She enjoys mentoring. She was also involved in the creation of a new employee handbook for all staff members on the CDI team to reference. Contributing every day along with the other team members of CDI Nurses is very important to the true bigger picture. Reporting to the Department of Quality & Safety, everyone contributes so much to patient and facility outcomes on the larger scale. The work of her team has a direct impact on the patient’s medical record as well as the facility. She enjoys being part of all of it.

Tricia S. McDonough, MS, BSN, RN-BC, CCDS, Clinical Documentation Improvement Specialist, earned her Master of Science in Health Informatics and Management and Bachelor of Science in Nursing from the University of Massachusetts. Certified in both Nursing Informatics and Clinical Documentation Improvement, she is passionate about improving healthcare outcomes through the use of data. With her strong nursing informatics background, Tricia brings technical expertise to quality projects in her organization that has led to improved medication safety practices, the optimization of clinician documentation, and improved communication methods among care teams at her previous employer. Tricia is excited to be part of the CDI Team at BWH as she continues on her journey to improve the quality of patient care and safety.

Trish Meyer, RN, BSN, CCDS, Clinical Documentation Improvement Specialist, joined the CDI team at Brigham and Women's Hospital in March, 2018, after previously holding CDI positions at both Mt. Auburn Hospital and Lahey Health. She originally received a diploma in Nursing at New England Deaconess Hospital, completed her BSN at Southern Adventist University, and became a CCDS in 2017. In her clinical nursing days, she was focused on critical care, primarily cardiac surgery, and PACU, although she also spent several years working in hospice and palliative care which she found very rewarding. She is proud to belong to the BWH CDI team and looks forward to many years on the BWH team!

Robert Sutherlin, RN, BSBA, Clinical Documentation Improvement Specialist, rejoined Brigham and Women’s Hospital in July, 2018. His nursing degree was earned at Rivier College in Nashua, New Hampshire, and he earned a business degree from Suffolk University in Boston. His career has encompassed many areas with the nursing profession including Oncology (Stem Cell Transplantation Unit), Cardiac (Step Down and Cardio/Thoracic PACU), SICU, Diabetes Research (published), Pulmonary Critical Care, and now Clinical Documentation. He has joined a team of extremely talented, experienced nurses in the CDI Department at BWH and has been welcomed as a colleague and nursing professional.

Joyce Williams, RN, MS, CCDS, CCS, Clinical Documentation Improvement Specialist, joined the CDI team March, 2019. Joyce graduated from Rhode Island College with a BSN and a Master of Health Service Administration from Salve Regina University. She has been a Registered Nurse for 31 years. Her experience includes Cardiac (telemetry/CCU), Nursing Supervisor, Case Manager, Clinical Analyst RN in revenue cycle, Pressure Ulcer Research Nurse, and CDI RN since 2009. She has also been a co-leader for the Massachusetts Association of Clinical Documentation Specialists chapter since 2016. She is thrilled to begin her career as a CDI specialist here at BWH!

Clinical Pathways Team

Casey McGrath, RN, MSN, Director of Clinical Quality Programs, earned her Bachelor of Science in Nursing and Master of Science in Nursing degrees from Endicott College. Prior to joining the Department of Quality and Safety in 2013, she worked as a staff nurse on the Intermediate Neuroscience Unit at Brigham and Women’s Hospital (BWH). Casey has worked closely with the Institute for Healthcare Improvement (IHI) Open School as well as Sigma Theta Tau Chi Epsilon members on quality improvement projects. At BWH, Casey has led quality reporting and improvement efforts in surgery, heart failure, the emergency department, the NICU, nursing, and catheter associated urinary tract infection (CAUTI) prevention. In the spring of 2015, Casey successfully launched the Brigham Surgical Quality Redesign (BSQUARED) effort, a program that enabled multidisciplinary provider-led teams from the departments of surgery, anesthesia, and nursing to develop and implement projects that transformed front-line clinical expertise into hospital-level improvements in surgical quality and safety. Through this program Casey facilitated the expansion of the hospital’s Enhanced Recovery After Surgery (ERAS) protocol to multiple service lines. Currently, Casey oversees the growth and development of the Clinical Pathways Program and the Catheter-Associated Urinary Tract Infection (CAUTI) Prevention Task Force. Casey is also responsible for providing vision and direction of many clinical quality initiatives throughout BWH.

Giavanna Gaskin, Clinical Pathways Data Coordinator, recently graduated with a Bachelor in Public Health from Massachusetts College of Pharmacy and Health Sciences. While at MCPHS, Giavanna received a prestigious award for her capstone project which focused on cultural competency of health care providers from the women’s perspective during the pregnancy experience Additionally, she has been part of the Brigham family for nearly two years, most recently working as a Resource Specialist in Care Coordination. Currently Giavanna is a member of Clinical Pathways Program team within the Department of Quality and Safety. In this role, Giavanna concentrates on improving the care of Enhanced Recovery After Surgery (ERAS) patients with a focus on compiling process and outcome data.

Courtney Nolan, Clinical Pathways Data Coordinator, received a Bachelor of Science in Psychology with a minor in Biology from Western New England University. Additionally, she completed her Master of Public Health at Boston University in May 2018. Courtney has been part of the Brigham family for the last year working as a Research Coordinator. Prior to this role, Courtney worked as a research assistant at both Boston Children’s Hospital and Western New England University. As a member of the Clinical Pathways Team within Department of Quality and Safety, Courtney utilizes ERAS (Enhanced Recovery After Surgery) pathways to focus on monitoring and improving surgical outcomes data.

Sharon Woo, Clinical Pathways Data Coordinator, received her Bachelor of Science in biochemistry from University of California, Los Angeles. Then she received Master of Science in Medical Physiology and a Master of Business Administration from Case Western Reserve University in Cleveland, OH. Prior to joining the BWH Quality and Safety Team in 2018, she worked as a clinical research coordinator at Cleveland Clinic in overseeing the regulatory and data aspects of clinical trials in hematologic oncology. As part of the Clinical Pathways Program at BWH, Sharon manages the ERAS (Enhanced Recovery After Surgery) Interactive Audit System to monitor compliance and identify opportunities for improvement in eliminating variation and improving quality.

LEARN MORE ABOUT BRIGHAM AND WOMEN’S HOSPITAL


For over a century, a leader in patient care, medical education and research, with expertise in virtually every specialty of medicine and surgery.

About BWH