Quality Program Manager
- Location: Boston, MA
- Posted: Dec 15, 2018
Quality Program Manager-(3080159)
The Manager of the Hospital Quality Program is responsible for overseeing the BWFH external Quality reporting programs, management of the Quality department staff members, and supporting the internal clinical quality improvement initiatives within the BWFH Department of Quality. S/he will work with the Executive Director of Quality in strengthening the hospital-wide quality outcomes measurement, reporting, and improvement activities, providing comprehensive leadership, management and facilitation of the hospitals quality reporting process and its strategic quality initiatives. . The Director will coordinate reporting and improvement activities across multiple operational departments concurrently. S/he will serve as a highly visible, energetic champion of quality throughout the organization. The Quality Manager will assure compliance with all external reporting mandates and improvement initiatives. In addition, s/he will be responsible for managing complex clinical data bases relating to Quality Improvement activities iSupporting quality initiatives in an interdisciplinary environment is essential The Quality Manager will coordinate multiple projects, improvement activities and deadlines.
1. Supports hospital leadership in facilitating quality improvement activities relating to regulatory mandates and internal quality improvement initiatives. The Quality Manager is the content expert on federal and state regulatory, third party, and accreditation requirements relating to Quality Assurance and Improvement initiatives. The Quality Manager is responsible for understanding and communicating reporting requirement to leadership . The Quality Manager assists in the identification of barriers to implementing improvement plans and in the development of strategies to overcome these barriers.
2. Independently provides comprehensive direction, oversight, and project management for a variety of quality measurement and improvement initiatives at BWFH. Examples include:
3. Works with Brigham Health IS to develop IT solutions for data capture and reporting utilizing the electronic health record (EHR). Works with Quality staff to engage front line staff members in process improvement activities as needed.
4. Collaborate with Quality Leaders at BWH to improve quality across Brigham Health as directed by the BWFH Executive Director
5. Works with Quality and Safety leaders throughout Partners to summarize findings, develop measurement strategies, make recommendations for corrective action or improvement as needed and tracks the impact of implemented changes of EHR and reporting changes on assigned performance measures and projects.
6. Provides consultation and assistance to Service Chiefs, the Department of Nursing, and hospital leadership in developing analytic and measurement strategies for QI projects. Same as 16 or can be combined?
7. Provides day to day oversight of clinical data management, including collection, data entry, and reporting activities to support hospital participation in quality improvement programs, including ACS programs such as NSQIP, TJC CORE Measures, CMSs National Hospital Quality Measures, MassHealth, Massachusetts Department of Public Health, and Partners IPF measurement and reporting requirements. Leveraging Brigham Health and Partners resources .
8. Assists the Executive Director of Quality in overseeing the National Hospital Quality Measures Program and development of related staff education and interventions, data collection and compilation via use of extracts, concurrent and retrospective chart reviews, entry of clinical data into the Vizient National Hospital Quality Measures database for all eligible patient cases, and interpretation, presentation, and distribution of National Hospital Quality Measures results to a wide audience of care providers.
9. Maintains a basic understanding of DSS Tableau Dashboards. Continuously provides feedback to ensure Dashboards are valid and relevant. Advocates for new dashboards as needed and helps design/develop content.
10. Assists the Executive Director of Quality in coordinating other mandatory or voluntary reporting requirements to regulatory agencies and payors, such as the Board of Registration in Medicine and Leapfrog.
11. Works with departmental quality leaders to investigate quality concerns or issues arising from external payor reviews (Tufts, MassPRO, HPHC, etc.), external clinical benchmarking efforts (Vizient, Partners, Joint Commission, etc.), or tracking of surveillance major outcome measures (e.g., mortality, readmission, and re-operation rates). Oversees medical record chart reviews when needed as the primary means of investigating such concerns, as well as interviewing relevant clinical staff and leadership; works with Executive Director of Quality and local quality leaders to summarize findings, develop recommendations for corrective actions or improvement projects as needed, and track the impact of implemented changes.
12. Maintains expertise with data abstraction specifications and emerging trends in hospital quality and reporting initiatives. Rapidly identifies, problem solves, and communicates to leadership any issues that are jeopardizing deadlines or scope. Utilizes a variety of performance improvement tools and methodologies, supporting the Quality and hospital teams in the use of concepts such as high reliability design, rapid cycle testing, frequent data sampling and feedback, workout strategies, etc.
13. Provides staff education to nurses, physicians, house-staff, clinical departments, committees, and others regarding concepts of quality outcomes measurement, major BWFH quality outcomes initiatives, external quality benchmarking programs, etc. Includes presentations to leadership groups (such as QSC), program Committee meetings, and staff meetings.
14. Supervise activities of Quality staff; oversee recruitment, interviewing, training, professional development, and evaluation of quality programs staff. Develops orientation and remediation materials as needed.
15. Participates in ad hoc medical record chart reviews as the primary means of investigating quality trends; works with the Executive Director to summarize findings, develop recommendations for corrective actions or improvement projects as needed, and track the impact of implemented changes.
16. Establishes effective and collaborative working relationships with members of the hospital community, clinical departments, administrative departments, hospital committees, and quality and safety staff across the Partners Health System.
17. Keeps current with data abstraction specifications, emerging trends in hospital quality and reporting initiatives, and integrates key concepts into work.
18. Participates in facilitating executive level hospital committees and task forces within the hospital and serves as a member of Partners-wide committees.
19. All other duties as assigned
Brigham and Women's Faulkner Hospital is a 171- bed non-profit, community teaching hospital located in Jamaica Plain directly across the street from the Arnold Arboretum. Founded in 1900, Brigham and Women's Faulkner Hospital has a long history of meeting the health care needs of our patients by offering comprehensive care in a wide variety of specialties. At Brigham and Women's Faulkner Hospital, our world revolves around our patients and their families, which is why weve been nationally recognized for our best practices in patient care, safety measures and surgical outcomes. If youre looking for more than a career, join Brigham and Womens Faulkner Hospital. Our patients call it better care. Our employees call it home.
Bachelors Degree in Nursing, science, or healthcare related field required
Masters degree and 2-4 years relevant work experience, strongly preferred
Experience in quality measurement and/or improvement, patient safety, or health science research required
At least one-year experience managing staff and complex programs strongly preferred
Experience working in a health care organization, teaching hospital or similar health care organization preferred
Knowledge of state and federal regulations specific to external reporting mandates preferred
Relevant experience preferred in using one or more performance improvement strategies such as IHIs Rapid Cycle Testing, Reliability Theory, GEs Change Acceleration Process in quality improvement and project management work
Demonstrated proficiency in data management relating to external regulatory requirements and vendors (DPH, ACS, CMS, TJC)
Experience in developing, planning, and implementing specialized clinical data bases
Expertise in the interpretation and communication of state and federal regulations specific to external reporting mandates
Staff adheres to all I C.A.R.E. Standards
Knowledge of state and federal regulations specific to external reporting mandates preferred
Strong computer skills (Word, Excel, and PowerPoint applications) with ability to utilize spreadsheet and graphic programs to produce bar graphs and charts required
Clinical chart review and abstraction experience required
Database data entry and/or management experience required
Superior organizational and interpersonal skills with ability to work independently
Excellent communication and follow-up accompanied by the ability to analyze and present data in a way to influence and change behavior
Creativity and enthusiasm for developing and implementing new programs
High degree of professionalism, discretion, and confidentiality
Solid report-writing skills with a demonstrated ability to communicate complex data in a clear and understandable fashion to hospital leadership
Comfortable interacting with a wide range of administrative and clinical staff, ranging from the Chief Medical Officer and department Chairs, to frontline care providers
Experience with performance improvement methods
Excellent project management skills with experience in planning, facilitating, and organizing improvement teams, task forces, and executive level hospital committees
Highly confidential data and medical records materials require extreme discretion
Ability to meet strict timelines
Expertise in the manipulation and management of clinical data bases, including skill in conceptualizing and building reports for special reviews.
Brigham and Womens Faulkner Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to an employees protected status, such as age, race, sex, color, ancestry, religion, national origin, physical or mental disability, veteran status, citizenship, gender identity or expression or sexual orientation