Director of Quality, Department of Medicine

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Integration Role

Job Summary

General Summary/Overview Statement

The Administrative Director for Quality reports to the Vice Chair of Quality, Assistant CMO for the Department of Medicine. The joint MGB Department of Medicine is a large complex department with >4000 faculty members, trainees, advanced practice providers and staff. This leader has the primary responsibility of assisting the Vice Chair Asst CMO in the execution of the core MGB Office of the Chief Medical Officer (OCMO) functions within the division, including:
Outcomes
Safety
Credentialing and privileging
Clinician (APP and Physician) minimal proficiency standards and professionalism (including oversight of OPPE and FPPE)
Patient experience
Health equity
Clinician well-being

The Administrative Director for Quality will collaborate closely with other department administrative teams, department clinicians and nurses as well as site based MGB Quality teams to execute upon daily activities related to these domains and to help implement strategy that is developed by the MGB OCMO, and at the direction of the Vice Chair for Quality/Asst CMO. This role will partner with the embedded MGB teams in Quality, Safety, Compliance, Infection Control, Patient Experience, Equity and Patient and Family Relations to ensure that the Department delivers the highest quality of care in the nation. This leader, in collaboration with the Vice Chair for Quality/Asst CMO, will also serve as a key conduit to disseminate information from the AMC and MGB Q&S teams to the Department and joint medical divisions, to ensure effective communication and execution of our strategic goals.

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 local hospital and department leadership, Patient Care Assessment Committee (PCAC), Medical Staff Leadership, Nursing Leadership, physicians, department managers, and all stakeholders. This role will collaborate with system and site leadership to execute long and short-term goals for the system and the department.

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

Principal Duties and Responsibilities

General Responsibilities
Support the Vice Chair of Quality/Asst CMO in executing all strategic quality goals and performance improvement within the department.
Coordination of department Quality meetings, agendas, deliverables, and programs.
Liaise with Department Operations and Nursing colleagues to ensure that goals are met, and work is collaboratively and efficiently completed.
Liaise with embedded MGB hospital leaders and teams to ensure that the department is meeting its quality objectives and collaborating/accountable for department level improvements that support the broader hospital and system goals.
As appropriate, represents the Vice Chair of Quality/Assistant CMO as needed at various internal leadership meetings as well as to external audiences.
Communicates proactively with the department and serves as a conduit for bidirectional communication between the department and system/hospital teams.
Supports clinical communications across MGB AMC environment related to the above domains.
Works closely, as appropriate, with site based MGB leaders and broader MGB teams as it relates to quality, safety, infection control, equity, clinical compliance, professionalism, provider well-being and patient experience.
Serves as department administrative leader to embedded enterprise hospital quality teams including those supporting Medicare Value Based Purchasing, Hospital Acquired Conditions, Hospital Readmission Reduction programs, and Mass Health Clinical Quality Incentive and Clinical Equity Incentive.

Specific Duties
Quality

Supports the Vice Chair of Quality, Assistant CMO in presentation of department performance metrics to stakeholder groups.
With the Vice Chair of Quality, Assistant CMO, leads Department Quality & Safety Committee, tracks performance of all divisions on all domains. Supports biannual performance reviews for all divisions.
Serves as the department administrative contact in support of embedded enterprise team members for clinical compliance, risk management, and patient safety, including conduct of safety event evaluations and mitigation, and Joint Commission surveys and other regulatory site visits and inquiries (DPH, BPHC, etc.).
Utilizes data from safety reports and coordinates with MGB Quality and Safety leadership to analyze trends, identify and prioritize patient safety and quality improvement opportunities, and propose mitigation plans.
Supports the Vice Chair of Quality/Asst CMO and hospital clinical compliance teams in executing site level-preparedness for surveys at the hospital.
Supports the Vice Chair and Division Quality leaders in performing Collaborative Case Reviews as well as ensuring corrective action plans are performed and action plans completed in prespecified/appropriate timeframes.
Supports and assists physician staff involved and liaison with hospital risk management as needed in management of safety events that require disclosure.
-Works closely with Vice Chair of Quality, Assistant CMO and department, hospital and system clinical operations teams as needed to improve on key performance metrics and implement quality improvement initiatives.
-Leads and oversees complex performance improvement projects spanning multiple divisions and role groups, ensuring timely and successful completion.
-Establishes the measurement approach and analytic strategies for assigned projects, including identification of key metrics, data sources and data collection plans, working collaboratively with MGB data and analytics team as needed.
-Oversee project logistics and communication (e.g., meeting agendas, slide decks) to ensure activities are tracked and are consistent with plans.
-Expertly leads the transition of assigned project results to the operational process owners at the time of project closure, including developing a feasible plan to sustain and spread the improvements to establish analytic strategies to monitor the outcomes of assigned projects.
Aligns the Academic Medical Centers (AMC) Ongoing Professional Performance Evaluation (OPPE) and Focused Professional Performance Evaluation (FPPE) processes for each division with the those of the department. Lead the tracking and reporting for OPPE and FPPE.
Supports the Vice Chair in improving any and all quality metrics as defined by the system, AMCs or department as being prioritized and having opportunity.
Supports advancement of ambulatory quality goals of the department in collaboration with MGB CMO and Population Health Management teams.
Manages and disseminates reports related to clinical documentation integrity for the staff.
Leads team of data abstractors across MGB AMC Department of Medicine and works with MGB OCMO and analytics team to:
-Direct operational aspects of the clinical quality reporting databases including requirements needed for accreditation.
-Oversees the work of the clinical quality data abstractors, including checking the accuracy of work prior to external and internal reporting, and providing support and direction as needed in order to achieve maximum efficiency.
-Perform regular evaluations for all registry staff.
-Works with MGB and division teams to provide performance data at least twice a year. Supports process improvement to address areas of opportunity. Prioritizes ad hoc division and department data request.
-Coordinates and leads data vendor relationships with internal and external clinical and administrative data repositories.
-As needed, partners with system wide MGB data teams to develop strategy, planning, and execution of any transfer of existing registry assets.

Credentialing
Assist the Vice Chair/Asst CMO or their delegate in managing the process of credentialing and privileging staff.

Patient Experience
Supports the Vice Chair of Quality/Assistant CMO and the Chief Patient Experience Officer (CPEO) in implementing the MGB patient experience initiatives within the department.
Serves as a department administrative support partner for embedded enterprise team members for patient family relations, facilitates investigations of patient complaints and grievances and supports resolution of these.
Ensures tracking and documents status updates of patient complaints that are identified through patient experience surveys.

Health Equity
Assists the Vice Chair of Quality, Assistant CMO in implementation of system wide health equity activities that align with MGB United Against Racism strategy.
Coordinates activities within the division in support of MGB and Department equity initiatives.

Well-Being
Prepares reports as needed on Well-Being within the Department.
Supports the implementation of departmental and system-initiatives to address provider well-being in the department.

Professionalism
Supports the Vice-Chair of Quality, Assistant CMO or their delegate in managing an ongoing portfolio of minimum proficiency requirements in appropriate knowledge, skills, abilities and behaviors for clinicians, and oversees administrative management and execution on the OPPE and FPPE programs.
Supports the Vice Chair of Quality/Assistant CMO or their delegate in managing concerns related to clinician knowledge/skills/ability/behavior, as well as ensuring execution and compliance with corrective action plans and performance improvement activities.
Liaises as needed with hospital HR and OGC departments in both proactive and reactive clinician management situations.

Qualifications

Qualifications and Skills Required

• Strong preference given to candidates with experience within MGB system.
• Advanced business or healthcare administration degree desirable but not required.
• A minimum of three (3) years of progressive responsibilities in leadership in a hospital setting or large health care organization with proven leadership and management skills.
• Knowledge and expertise within the department preferred, but not required. Knowledge and expertise of departmental organizations and clinical care structures required.
• Capable of working in an extremely complex academic medical center as part of a large integrated delivery system with many matrixed relationships.
• Must be a skilled communicator and team-builder.
• Experience in quality improvement, safety event evaluation, health equity, and patient relations/ service recovery preferred.
• Exemplary interpersonal communication skills required to interact effectively with senior management and physicians on sensitive political and confidential issues.
• 1.0 FTE; role will primarily be on the ground at both AMCs with occasional opportunity for remote work.

Additional Job Details (if applicable)

Remote Type

Onsite

Work Location

55 Fruit Street

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement:

Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veterans Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at .... Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.