Massachusetts General Hospital Patient Care Services
Excellence Every Day


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Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.
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What is the patient experience?

family photoWhen patients come to the hospital, they have an experience that crosses boundaries, buildings, departments and disciplines.  While we think most often of the part of the experience we are most connected with, patients see their time with us as a whole.  The experience begins with the drive to MGH and ends when they arrive back at their home or at the next level of care. 

The patient experience also includes all aspects of the care we provide, including Quality, Safety and Service.  All aspects need to be attended to in our daily work.  That is why so many of our quality, safety and service initiatives are linked – because although we think of these areas separately as we work on them, there is really only ONE patient experience.  At MGH, our goal is to achieve Excellence Every Day in each of these three areas.

Providing an excellent patient experience also involves every member of the team. Every one of us can help shape the experience, regardless of our role.

Finally, the patient experience most often includes families and other loved ones.  As we care for patients, we must also take these key people into account, including them, being sensitive to their needs and their involvement.  In other words, we strive for a patient experience that is patient and family centered. 

This page outlines efforts, resources and tools that help support the provision of an outstanding experience for our patients and families. Click here to see select samples of how MGH staff impact the patient experience.


The Patient Satisfaction Survey ProcessHCAHPS logo

How do we know we are providing the best experience for our patients? The Patient Satisfaction Surveys show us by completing a picture of the overall patient experience.
These surveys provide valuable data and comments on how our care and service was perceived by those we serve.  We can use this data to see which areas are our strengths
and which need improvement.

Here are some additional resources:

  • “Patient Experience Surveys at MGH" poster
  • Patient Experience Sharepoint site This is a central site for leaders to access patient experience reports and other resources pertinent to inpatient and ambulatory care settings that are posted. (internal access only)
  • Quality Data Management (QDM) Portal This portal is available for leaders to get the most current survey results for inpatient and ambulatory care settings. To gain access contact Liza Nyeko at (internal access only)

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We use data to improve the patient experience. The data helps us see how we are doing on important aspects of quality, safety and service. And, we use data to target our focus and efforts. Here are some of the data on these key aspects of the patient experience.

New inpatient experience reports are available for review:
(internal access only)

Adult Inpatient Reports

  • HCAHPS Focus-Level Report: reflecting adult hospital patient experience survey results by clinical service. This report presents one page for each of the composites/measures reported publicly. Each page includes a service-level bar chart and an aggregate MGH control chart.
  • HCAHPS Unit-Level Report: reflecting adult hospital patient experience survey results by patient care unit. The structure and format of this report are comparable to the above, with a unit-level bar chart and an aggregate MGH control chart presented on each page. 

Pediatric Hospital Report
Please note that pediatric hospital results are not comparable to HCAHPS results, as the survey questions differ.)

  • Pediatric Hospital Focus-Level Report: reflecting adult hospital patient experience survey results by clinical service. This report presents one page for each of the composites/measures reported publicly. Each page includes a service-level bar chart and an aggregate MGH control chart.
  • Pediatric Hospital Unit-Level Report: reflecting patient experience survey results by patient care unit. This report presents a unit-level bar chart and MGHfC aggregate control chart for each measure included, as well as patient/family comments and a “Report History Table" at the end of the report.

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patient care imageOnce an aspect of care is identified as needing improvement, we deploy best practices to help address the issues.  At MGH, we use best practices that have been proven to work over time in hospitals like ours.  Using an evidence based approach helps to ensure that our time and effort are well spent and productive.  Here are some of the best practices currently be used or rolled out at MGH.

Relationship Based Care

Relationship Based Care Slide

In the Literature

Addressing Quietness on Units
A quiet environment offers a healing environment for our patients.  Noise is such a stressor for patients that it is proven to be detrimental to their healing process.  For many patients, sleep is an important part of their recovery.  We need to do everything possible to ensure that our patients get as much rest as they possibly can.

Discharge Phone Calls
The Discharge Phone Call program at Mass General ensures that our patients receive a call—from a nurse on the patient care unit from which they were discharged—within 24-48 hours of discharge. Our nursing staff makes more than 75,000 calls each year…or more than 1,400 calls per week! The goal is to ensure they are safely at home safely and have the resources they need to take care of themselves. This program helps prevent readmissions by proactively reaching out to patients and preventing problems before they occur or worsen.  In addition to improving safety and quality of care, research shows that patients who receive discharge phone calls are more satisfied with their overall experience at the hospital. Program Details...

For more information about Discharge Phone Calls, please contact project specialist Kevin Knoblock, NP, MSN, MBA.

Service Recovery Program
When a service breakdown occurs, patients expect us to show that we care by listening, empathizing, acknowledging the situation and by doing the right thing.  They don’t expect us to be perfect, but they do expect us to offer options or to fix things then they go wrong.

Patient & Family Advisory Councils (PFACs)Patient & Family Advisory Council in action
The MGH Patient Family Advisory Councils (PFAC) provide a formal communication vehicle for patients and families to take an active role in improving the patient experience at the MGH. The councils focus on discovering what programs and practices represent the most successful patient and family experience within MGH and help to replicate and share those best practices across the entire community.  Our vision is to achieve a level of care where patient and family involvement is expected and welcomed by all. We will achieve this through collaborative efforts between patients, families, staff, physicians and administration of the hospital.
MGH / MGPO PFACs include:

Patient  & Family Notebook and Discharge Information Envelope:
The Patient and Family Notebook is meant to help patients know more about their care team, understand ways that they can participate in their care, and get the information they need to care for themselves after they leave the hospital.  The discharge information envelope and “Going Home Checklist” is intended to help patients prepare for discharge and collect important information they will need to care for themselves after hospitalization.

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RESOURCES FOR LEADERS (internal access only)

The best way to improve MGH’s patient satisfaction ratings is for every unit and department that are measured on the survey to work on and improve their results.  This approach to improvement allows for each area to review the results from their own patients and families and select interventions or strategies that are tailored to address their improvement needs.  Here are resources for units or departments to plan for service improvement:

Improvement Planning
Here are some resources that help units and departments make effective plans for improvement.

Excellence Every Day Video
Improving service takes leadership and it is supported when every member of the team can see how they can help to contribute to the patient experience.  Here is a video produced at MGH that helps to communicate our vision and our roles.


Excellence in Action
The Excellence in Action Program seeks to recognize and reward those individuals and/or teams who have been highlighted in e-mail or letters of commendation received by administration, principally those delivered to Dr. Slavin or the Office of Patient Advocacy.

Patient Care Services Awards & Recognition Program
Patient Care Services (PCS) operationalizes celebrates and supports those employees whose daily practice demonstrates excellence in care and services to patients. Partnering with patients and families PCS has developed a comprehensive award and recognition program that celebrates clinical and support staff in their ability to serve patients and families of the MGH.
click here for more...

Annual Service Excellence Awards
MGH’s Annual Service Excellence Awards are meant to support the organization’s efforts to improve the patient experience and the ratings given to us by our patients and families.  Awards are targeted at reinforcing achievement of goals or significant improvement in metrics and at recognizing outstanding work by teams and leaders related to patient experience.

Rolling out the red carpet for the Service Excellence AwardsCaring Headlines (5/7/15)

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Service Excellence Department Team Members

Rick Evans
Senior Director

Kevin Knoblock, NP, MSN, MBA
Project Specialist

Sharon Badgett-Lichten, LICSW
Senior Organizational Development Specialist

Cindy Sprogis
Senior Project Manager

Andrea Wright
Program Manager

Beth Scott
Assistant to Senior Director


The Office of Patient Advocacy

The Office of Patient Advocacy (OPA) is responsible for managing the hospital's patient commendation and complaint process. (617) 726-3370 |

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Joint Commission logo

"The Joint Commission has made several efforts, both past and present, to better understand individual patients' needs and to provide guidance for organizations working to address those needs.  The Joint Commission first focused on studying language, culture, and health literacy issues, but later expanded its scope of work to include the broader issue of effective communication, cultural competence, and patient- and family-centered care.  No longer considered to be simply a patient's right, effective communication is now accepted as an essential component of quality care and patient safety.  Additional studies show that incorporating the concepts of cultural competence and patient- and family-centeredness into the care process can increase patient satisfaction and adherence with treatment."

(Effective Communication, Cultural Competence, Patient- and Family-Centered Care: A Roadmap for Hospitals,
published by The Joint Commission , 2010)

Magnet Recognition

Magnet_logoThe American Nurses Credentialing Center (ANCC) requires Magnet-designated organizations to track nationally-benchmarked nursing sensitive indicators (NSIs) to continually inform improvement efforts related enhance patient outcomes. Examples of NSIs include, but are not limited to: patient falls, hospital-acquired pressure ulcers, blood stream infections, ventilator-associated pneumonia, and restraint use.





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There are numerous terms and acronyms in healthcare that may be unfamiliar. Please click here to visit a Glossary of Terms that may be helpful. And please email any suggested additions.

This month's featured term: HCAHPS
l Consumer Assessment of Healthcare Providers and Systems (HCAHPS or CAHPS Hospital Survey) is a standardized survey instrument and data collection methodology for measuring patients' perspectives of hospital care. While many hospitals collect information on patient satisfaction, there is no national standard for collecting or publicly reporting this information that would enable valid comparisons to be made across all hospitals. HCAHPS is a core set of questions that can be combined with customized, hospital-specific items to produce information that complements the data hospitals currently collect to support improvements in internal customer service and quality-related activities.

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Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.

If you have questions or suggestions related to the EED portal, please contact Georgia Peirce at (617) 724-9865 or via email at

updated 8/24/15


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