Kelly Doorley is the Executive 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 Mass General Brigham including staff nurse at Massachusetts General Hospital, Compliance Manager at Mass General Brigham 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.
Karen Fiumara is the Vice President for 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.
Deb Jones is the Director of Clinical Documentation Improvement. Deb 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.
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.
Kate Ulbricht is the Senior Director of Clinical and Academic Programs. She received her Bachelor of Science from the University of Connecticut, her Doctor of Pharmacy from the Massachusetts College of Pharmacy and Health Sciences University, and her Master of Business Administration from Northeastern University in Boston. 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.
Zoe Burns, MPH, Patient Safety Program Manager, earned her Bachelor of Science in Legal Studies from the University of Wisconsin - Madison, and her Master of Public Health from Boston University where she concentrated in Health Policy and Management. In her role on the safety team, Zoe focuses on the prevention of delayed or missed diagnoses through the Ambulatory Safety Net program.
Prior to joining Brigham and Women’s Hospital in 2018, Zoe worked in administration and clinical operations at Boston Healthcare for the Homeless Program. There she co-founded and managed a weekend women’s clinic, serving as an Emergency Department alternative, and a safe space for patients living in shelters and on the streets to seek care. She was a Project Manager in BWH’s Center for Patient Safety Research and Practice before joining the Department of Quality and Safety. Zoe is driven by the desire to improve patients’ quality of life and the patient experience. Her career has focused on patient safety, process improvement, and program development / implementation / evaluation. She spends time outside of work volunteering on various patient advocacy initiatives.
Deborah Darveau, RN, BSN, Senior Patient Safety Specialist, earned her Bachelor of Science in Nursing from Rhode Island College. She worked as a staff nurse in Labor & Delivery and the Step-Down ICU at Women and Infants’ Hospital in Rhode Island. She was also a member of the Rapid Response and Code Teams. There she participated in Shared Governance Committee working to solve systems problems and update policies and procedures.
Deborah’s career is multifaceted ranging from founding a fitness business to managing an OB/GYN practice, then working on HEDIS metrics for an insurance company. Her many skills and interests lead her current focus on coordinating quality, safety, compliance, and risk programs. She has been in the Mass General Brigham family since 2016 when she started working at Newton Wellesley Hospital (NWH) as a Quality and Patient Safety Specialist. Deborah is a past Director on the Board of New England Health Care Quality, serving on the Membership Committee. She joined Brigham and Women’s Hospital Department of Quality and Safety in 2020 while maintaining a Postpartum per diem staff nurse position at NWH.
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.
Rossella Mastrocola, MPH, Program Coordinator, earned her Bachelor’s degree in Psychology at Rivier University in 2014. In 2018, she earned her MPH from Southern New Hampshire University. Prior to starting at BWH, Rossella worked at Lahey Hospital & Medical Center as the Project Coordinator for the Department of Quality & Safety. Rossella has always had a passion for working in healthcare, specifically in improving healthcare quality.
E. Ann Vispoli, RN, BSN, MS, CPHRM, Senior Patient Safety Specialist, earned her Bachelor of Science in Nursing from Seton Hall University in South Orange, NJ, and her Masters in Leadership and postgraduate certificate in Healthcare Management from Northeastern University in Boston, MA. Ann’s clinical experience includes emergency department staff nurse as well as assistant nurse manager. She joined the Mass General Brigham family in March 2021 from Winchester Hospital (BILH) where she was the Patient Safety Specialist. Ann is a Board Member of Massachusetts Society of Healthcare Risk Managers (MSHRM) and co-chair of the membership committee.
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.
Jo Ann David-Kasdan, RN, MS, SM, Lead Program Manager, earned a Bachelor of Science degree in Nursing from the University of Wisconsin-Madison, a Master of Science degree in Nursing from Boston University, and a Master of Science degree in Health Policy and Management from the Harvard School of Public Health. 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 quality improvement projects in various service lines, including the care of patients with diabetes, heart failure, and HIV, pediatric weight-based dosing, adverse events, and race and gender issues in kidney transplantation. On the quality team, she focuses on hospital-wide quality and reporting initiatives and spends a significant amount of time reviewing and improving patient safety indicators.
Evelyne Joseph-Noel, RN, MBE, Senior Quality Program Manager, earned her Bachelor of Science degree in Nursing from Northeastern University and her Masters in Bioethics from Harvard Medical School Center for Bioethics. Prior to joining the Department of Quality and Safety, she had worked as a staff nurse in the Emergency Department at Massachusetts General Hospital since 2004. She co-chaired the ED Ethics Committee, where she led clinical improvement projects addressing health disparities in vulnerable populations. She is a staunch advocate for health equity and is passionate about quality care delivery, patient safety, and improved patient outcomes. In her role on the quality team, Evelyne focuses on quality measures related to ED throughput, Outpatient Stroke, Endoscopy, and Oncology.
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.
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.
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 BWH'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.
Linda Cameron, RN, BSN, CPN, CCDS, Clinical Documentation Improvement Specialist, joined the Brigham and Women's Hospital Clinical Documentation Improvement (CDI) team in July of 2019. Prior to accepting this position, she was a CDI specialist for Lifespan Corporation for eight years. She has been a professional nurse for 38 years. Most of Linda’s clinical experience was in pediatrics at Hasbro Children’s Hospital in Providence, RI, as the PACU assistant manager and the clinical manager of the infant unit. Early in her career she cared for adult patients requiring cardiac surgery. She is extremely happy to be part of the CDI and Quality teams.
Maura Carrier, RN, BSN, CCDS, Clinical Documentation Improvement Specialist, joined Brigham and Women's Hospital's CDI program in March 2017. Prior to this position she worked in similar roles at Lowell General Hospital and Brigham and Women's Faulkner Hospital and as a Quality Improvement Specialist at Hallmark Health. Maura spent most of her career as a critical care nurse in the SICU at St. Elizabeth’s Medical Center, moving to the outpatient area as the Assistant Patient Care Director in Surgical Services. She earned her Bachelor of Science in Nursing from Emmanuel College in Boston and her nursing diploma from St. Elizabeth’s School of Nursing.
Ellen Downing, RN, BSN, CCDS, Clinical Documentation Improvement Specialist, has worked at Brigham and Women’s Hospital in Boston, MA, since 2001. Ellen earned her Bachelor of Science in Nursing at Salem State University after working as an LPN since 1977. Her years of nursing experience have traversed multiple clinical specialties and nursing settings such as Acute Care, Acute and Sub-acute Rehabilitation, Community Health, Case Management, and Quality Assurance.
At BWH, she established the Nursing Education Fund which awarded yearly scholarship funds for nurses pursuing advanced education in nursing. She served as a one-year member of the Chief Nursing Officer’s Nursing Focus Group and has served as a Magnet Champion during Brigham and Women’s Hospital Magnet Designation Journey. She is currently serving her second year as a member of Brigham and Women’s Hospital Magnet Council.
Ellen has held many prior certifications which include Certification in Case Management (CCM) by the Center for Certification in Case Management, Certified Professional in Utilization Review (CPUR), Certified Professional in Healthcare Management (CPHM) from McKesson, and Certification in Clinical Documentation from the Association of Clinical Documentation Specialists. She is currently pursuing her Master of Science in Nursing at Aspen University.
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.
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.
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.
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.
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