Who We Are

The Office of Performance Measurement & Reporting (PM&R) provides leadership in clinical quality and patient experience reporting for BHCS performance measurement initiatives. These initiatives include, but are not limited to, activities involving leaders and stakeholders at all levels across BHCS.

As Director of PM&R, Marisa Valdes, MSN, RN, CPHQ is responsible for staying abreast of regulatory matters that affect the measurement and reporting of BHCS performance metrics; collaborating with BHCS service lines, leaders, and clinicians to develop reporting initiatives; overseeing specified facility and system surveys; establishing measure documentation protocols; and monitoring the BHCS data reported by external entities.

Members of the PM&R team include:

Tricia N. Gray, BA, MBA, HPT - Senior Quality Process Improvement Consultant

Amy L. Alexander, RN, BSN – Quality Process Improvement Consultant

Toshika Jolivet, BSTM, MBA, CPC – Performance Measurement & Reporting Consultant

Alfreda J. Carr, MBA, DMS – Performance Measurement & Reporting Coordinator

Ruth A. Winborn – Performance Measurement & Reporting Executive Assistant

What We Do & How We Can Help

PM&R assists BHCS stakeholders in a variety of ways, including, but not limited to:

• Internal dissemination of quality improvement/clinical performance reports
• Research and development of clinical performance measures
• Project Management of quality improvement reporting initiatives
• Communication about quality, patient safety, and other required public reporting initiatives
• QualityNet user administration and support
• MIDAS+ ad hoc reporting
• Statit ad hoc reporting
• Administration of completion and submission of specified surveys