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Center for Quality & Safety

About the MaineHealth Center for Quality & Safety (CQS)

Patients and their families deserve to be informed about the quality of their heath care. At MaineHealth we are dedicated to being transparent with our performance and how we work to provide the best care for our patients. The MH Center for Quality and Safety coordinates patient safety, patient experience and quality improvement efforts and training across our health care system.


PATIENT EXPERIENCE - Care That is Responsive

How do we measure patient experience?

The MaineHealth Center for Quality and Safety analyzes and reports HCAHPS patient experience survey results as one way to ensure patients and families have a positive experience during their stay.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized national survey completed by patients and family members after discharge to provide information about their perspective of the experience of care they received at one of our MaineHealth hospitals.

The survey asks adult patients questions about discharge planning, communication with nurses and providers, cleanliness and quietness, pain management, the patient’s overall experience and more.

Patient responses are submitted to the Centers for Medicare and Medicaid Services, which publicly reports the quarterly results from all U.S. hospitals online at Hospital Compare. Internally aggregate and disaggregate data is reported on a quarterly basis on the MH System Measures Board Quality Board Report.

Opportunities for Improvement / Next Steps

The MH Center for Quality and Safety works with our member and affiliate organizations, the MH Quality Improvement Council and the MaineHealth Patient Experience Workgroup, to share best practices, identify specific areas for improvement and discuss opportunities for standardizing care. System wide action plans have been developed and implemented.



PATIENT SAFETY - Care That Protects You From Harm

What are we measuring and why?

Leapfrog Hospital Survey

MaineHealth hospitals actively participate in the Leapfrog survey. The annual Leapfrog Hospital Survey assesses hospital safety, quality, and efficiency based on national performance measures. “ These measures and safety practices cover a broad spectrum of hospital services, processes, and structures and provide hospitals with the opportunity to benchmark their progress in improving the quality, safety, and efficiency of the care they deliver against others.” Leapfrog Hospital Survey results are publicly reported by hospitals, at

In addition to Leapfrog measures our system is working hard to improve many other patient safety measures including increasing hand hygiene compliance, reducing the number of patient falls and to improving the patient culture of safety.

Patient Safety Culture

Surveying hospital staff and health care providers about patient culture of safety is a good way to assess the environment and prevent patient harm. At MaineHealth we realize that preventing patient harm requires more than implementing best practices. It also requires a culture that embodies effective communications, shared values about the importance of safety, and the presence of systems processes and performance improvement tools that help organizations identify and learn from errors, and prevent them from occurring in the future. Higher patient safety culture scores are associated with lower rates of infections, nurse turnover, falls, pressure ulcers and other complications of care.

MaineHealth hospitals use the AHRQ Culture of Safety survey. The Patient Safety Group enables us to monitor trends in our safety culture survey results, as well as use the comparative data to evaluate our efforts to establish, improve, and maintain a culture of patient safety in our hospitals.

Opportunities / Next Steps

Through efforts of the MH Center for Quality and Safety, MH Quality Improvement Council, system wide work groups and other efforts we are able to share best practices, identify specific areas for improvement, discuss opportunities for standardizing care, and develop and implement action plans for improving performance across the system.





110 Free Street | Portland, Maine 04101 | (207) 661-7001