Senior Program Manager - Quality / 40 Hour / Days
Brigham & Women's Hospital
 Boston, MA

Under the leadership of the Vice President of Quality, the Senior Program Manager, Quality will help to strengthen the department’s hospital-wide quality outcomes, reporting, and improvement activities. S/he will develop and manage programs to comply with an increasing number of external reporting mandates and improvement initiatives. The Senior Program Manager, Quality is responsible for data collection, analysis, and reporting to a wide range of clinical, administrative, and executive leaders. S/he will provide comprehensive leadership, management, and facilitation for assigned clinical programs. The Senior Program Manager, Quality must be able to coordinate programs and improvement activities across multiple academic and operational departments concurrently and serves as a highly visible, energetic champion of quality throughout the organization. Extensive daily interaction with staff and senior leadership in the Department of Quality and Safety and throughout Brigham and Women’s Hospital (BWH) and Mass General Brigham (MGB) is a key component of this role.

Principal Duties and Responsibilities:

  1. Collaborates with service line chiefs and academic and operational departmental leadership at BWH to develop clinical quality improvement strategies and implementation plans to ensure success on pay-for-performance metrics included in the Joint Commission, Leapfrog, the Centers for Medicare and Medicaid Services (CMS), the Mass Health Acute Hospital, and the Internal Performance Framework (IPF) programs.
  2. Performs medical record chart reviews for BWH and Dana Farber Cancer Institute (DFCI) as a primary means of investigating quality trends and completes data collection and analysis within established timeframes to ensure compliance with federally and state mandated public reporting requirements including, but not limited to, the CMS Inpatient and Outpatient Quality Reporting Programs (IQR/OQR), The Joint Commission ORYX Core Measures, and the Massachusetts Executive Office of Health and Human Services (EOHHS) Office of Medicaid.
  3. Under the direction of the Vice President of Quality and the Senior Director of Clinical Quality Improvement, collaborates with inpatient unit-based leaders throughout BWH to provide comprehensive leadership and program management for unit-based team initiatives. This includes working with clinical frontline staff and leaders to design and implement measurable and scalable improvement initiatives throughout the project life-cycle: i.e. from project selection and scope through implementation of a plan to establish new processes, monitor/analyze data results, and sustain associated improvements as well as facilitate unit-based team meetings.
  4. Assists the Vice President of Quality in the development and execution of hospital strategic and quality measures on the IPF slate including program management and oversight of select projects to ensure that all deliverables are met and financial incentives are earned.
  1. Assists the Vice President of Quality in strengthening technical coding practices and clinician documentation by reviewing patient records with flagged complications to ensure that all ICD10 coding accurately reflects the patient’s clinical course and complexity to ensure accurate risk-adjustment for administrative metrics used in government incentive/penalty programs. This involves frequent collaboration with frontline clinical staff as well as management and staff within the MGB Finance/Revenue Cycle Operations technical coding department and the BWH Clinical Documentation Improvement Program.
  2. Utilizes thorough understanding of the electronic health record (EHR/Epic) to improve quality process and outcomes measurement across BWH, MGB, and Partners eCare by ensuring that the EHR is designed to appropriately capture quality of care, including the creation of novel EHR quality and safety reports as well as the validation of existing quality reports to ensure accuracy.
  3. Serves as subject matter and improvement methodology expert on Partners eCare Clinical Content Build and Reporting committees and imparts knowledge to interdisciplinary team members, BWH Senior Leadership, and Partners eCare to mitigate problems and develop timely solutions.
  4. Assists the Vice President of Quality, Senior Director of Clinical Quality Improvement, Medical Directors, and Chief Quality Officer with the management of specified quality, patient safety, and domain team initiatives, including the development of project timelines, agendas, reports, and presentations to various audiences to support the strategic direction of the department and the institution.
  5. Educates nurses, physicians, house-staff, clinical departments, committees, and others regarding concepts of quality outcomes measurement, major BWH quality outcomes initiatives, external quality benchmarking programs, and optimization of functionality within the electronic health record.
  6. Co-leads planning of annual Patient Safety and Quality Improvement Conference. Plans scope of event, solicits bids from venues and vendors, creates agendas, monitors budgets, and coordinates other event logistics as needed for meetings with greater than 200 attendees.
  7. Designs and monitors the Quality and Safety website; updates publicly reported data and promotes new project work and other hospital-wide achievements.
  8. Maintains expertise with data abstraction specifications and emerging trends in hospital quality and reporting initiatives and manages the resources and deliverables for assigned programs. Rapidly identifies, problem solves, and communicates to leadership any issues that are jeopardizing deadlines or scope.
  9. Establishes effective and collaborative working relationships with members of the hospital community, clinical departments, administrative departments, and quality and safety staff across the MGB Health System.
  10. All other duties as assigned.

  • Bachelors degree in nursing, science, or healthcare related field required
  • Masters degree or 2-5 years relevant work experience preferred; required if non-clinical
  • Experience in quality measurement and/or improvement, patient safety, or health science research preferred
  • Experience working in a large and complex health care organization preferred
  • 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, are required for this position

Skills/Abilities/Competencies

  • Superior organizational and interpersonal skills with ability to work independently
  • Excellent creativity, enthusiasm, and flexibility for developing and implementing new programs
  • Strong management skills with experience in planning, facilitating, and organizing improvement programs
  • Problem-solving ability, data management, and analytic skills
  • Experience with performance improvement methods, including statistical concepts and applications
  • Ability to manage time and resources effectively to meet deadlines
  • Demonstrated effectiveness as a team member, team facilitator, and team leader
  • Excellent communication and follow up accompanied by the ability to analyze and present data in a way to influence and change behavior
  • Comfortable interacting with a vast array of administrative and clinical staff, ranging from frontline providers to senior and executive leadership
  • Working knowledge of Electronic Health Records
  • High degree of professionalism, discretion, and confidentiality
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