Senior Manager, Quality, Spaulding Network

Site: The Spaulding Rehabilitation Hospital Corporation

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

 

Job Summary

This role reports directly to the MGB VP of Hospital Quality and is responsible for the success of a broad quality program within Spaulding Rehabilitation Network. This role will partner with the MGB VP of Quality and the Spaulding executive leadership to execute a robust and comprehensive quality strategy at SRN, including performance analysis, tracking and improvement. This role will lead a team of local quality team members who focus on day-to-day oversight, coordination, execution, and implementation of all quality activities at the site.
This role will maintain sound organizational relationships, work well within a matrixed and integrated health care system, and will be facile in performing bi-directional communication with MGB leadership as well as site level leaders and clinicians.

Because this is a management role in an active change management environment, this individual will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time.

 

Qualifications

Responsibilities

• Execute the MGB quality strategy at SRN ensuring adherence to MGB standardized processes around quality measurement, strategy, prioritized areas, and performance improvement. Provide input and feedback from SRN to the system leaders in quality as needed to inform approach as it relates to SRN.
• Execute organizational model for the personnel and infrastructure for the quality team at SRN, ensuring that all team-members follow standardized and best-practice procedures and approach to all quality performance and improvement activities. Perform local management and review of these staff.
• Responsible for performance on all CMS conditions of participation, government and private payer pay for performance activities in the quality and equity domains at SRN. Responsible for performance on key MGB quality priorities. Identify areas at risk and with bidirectional communication and planning with MGB leadership, develop performance improvement planning to ensure we achieve all quality goals at SRN.
• Responsible for partnering with the MGB data and analytics team to ensure that reporting to CMS and other regulatory bodies, private payer contracting, external benchmarking bodies, PSIs, HACs, NHSN reporting, Leapfrog, etc is timely and correct.
• Advise in the creation of any needed MGB or SRN level dashboards around quality performance and improvement.
• Specific activities and coordination required:
  • Liaise as needed with Safety teams to implement performance improvement as a result of safety events. Partner with safety team as needed prospectively to create performance improvement in pursuit of harm avoidance.
  • Liase as needed with site infection control team to monitor and improve performance, and respond to data to lower the risk of infections to our patients.
  • Liase as needed with the local clinical documentation improvement team to ensure clinicians are capturing the patient's burden of disease and disease complexity.
  • Partner with the SRN leader of clinical compliance in all site visits and regulatory reviews. Responsible for working with the SNR leader of clinical compliance to assess emerging risks for SRN, and subsequent performance improvement activities/feedback and accountability for local teams.
  • Liase with the SRN CMO as needed to execute system goals and sit level improvements.

• Leads proactive and reactive quality performance improvement plans, and partner with local teams and department or floor-based teams to improve or implement key improvements as needed. Leads the planning, implementation and evaluation of process changes or performance improvement activities. Able to effectively and persuasively communicate goals, strategic planning, and accountability processes with department chairs and enlist the partnership of departmental teams for success.

• Responsible for QAPI planning and documentation, and updates as needed for board quality committee/patient care assessment committee.
• Prepares reports and presentations as needed.
• Oversee local training and educational programs as needed.
• Understan