A community health system based in New Bedford, Mass., made a sustained investment in data transparency and frontline engagement to drive measurable gains in quality and patient experience.
Southcoast Health recently earned its second CMS star rating upgrade in the past three years, along with a 2025 NRC Health award for excellence in patient experience following a multiyear effort to strengthen performance reporting and operational discipline.
The gains come as hospitals nationwide face mounting pressure to improve quality care amid tighter margins, workforce strain and growing public transparency. For many community health systems, sustaining quality improvement has been challenging as leaders balance investment in analytics, clinician engagement and day-to-day operations. Southcoast’s experience underscores how long-term cultural change, rather than short-term fixes, can move performance metrics in a measurable way.
The nonprofit health system serves a catchment area of about 700,000 patients across three hospitals in Massachusetts. Its approach has focused on embedding data into daily workflows while pairing technology with process improvement.
“The work is data driven, employs robust process improvement approaches familiar to most organizations,” Dan Hackner, MD, chief clinical and academic officer of Southcoast Health, said during an interview with the “Becker’s Healthcare Podcast.” “For us, it requires that balance between hardwiring technology, but also a deep attention to human factors at work.”
That balance shows up in daily operations across the system. Units use digital whiteboards to track patient throughput and progression of care, hold daily 11 a.m. huddles, and conduct systemwide safety huddles where staff gather to surface concerns and share learnings.
“Whether you’re wandering from a digital whiteboard that transparently maps patients’ throughput and progression of care huddles that occur every day in every unit, or you come across our daily safety huddles every morning where our staff physically gather and share, the good and the bad, celebrate harm avoidance or report issues without any fear or any worry, or you go to one of our recognition programs for excellence in compassionate care,” Dr. Hackner said. “All of these elements share a common thread: concurrent data, engaged discussions, and empowerment to lead.”
Early in the journey, the system encountered resistance, particularly around the use of real-time performance data and its implications for leaders and board members.
“I’ll be very honest. Early on, there were some folks who were worried about this deeply data-driven approach,” Dr. Hackner said. “Were folks ready to accept concurrent data? Were they able to? Were board members prepared and were leaders willing to accept some hard data that is tough to to face?”
Over time, Dr. Hackner said data literacy and comfort with performance transparency improved across the organization, including at the governance level.
“We have a board quality and safety committee and we put up a cause and effect diagram, a fishbone diagram, this is not a surprise,” he said. “This is something as expected by board members using debriefings and validated approaches to achieve safety improvement.”
The system has also expanded who leads improvement work. Nurses and other frontline clinicians are increasingly running debriefings and root cause analyses, reinforcing a broader culture of psychological safety.
“It really is a joy to see a professional practice nurse lead one of these debriefings and expand the number of folks who can run RCA initiatives,” Dr. Hackner said.
The work has required sustained trust-building and a willingness to sit with discomfort, he added. Dr. Hackner is a proponent of psychological safety and creating a culture where team members feel empowered to talk about missteps to accelerate whole-team growth and improvement. Looking ahead, Southcoast plans to deepen that alignment at the board level, with more than one-third of its board scorecard tied to quality and experience metrics.
“There is definitely gratification in seeing these community teams advance our mission,” he said.
