Senior Program Manager, Quality & Safety, Department Of Surgery

GENERAL SUMMARY/ OVERVIEW STATEMENT:

Under the direction of the Department of Surgery Quality Chair, and in partnership with the Executive Director of Surgery and the Codman Center for Clinical Effectiveness in Surgery (CCCES), the Senior Program Manager will play a critical role in the mission of the Department to improve the quality and safety of clinical care through project management of priority initiatives, safety event tracking and process improvement, quality measurement and monitoring, regulatory readiness, and department education and research efforts. This leader will also serve as the main conduit to disseminate key information from the MGH and MGB Q&S teams to the Department and each Surgical Division, to ensure effective execution of our strategic goals.

The ideal candidate will have excellent communication and interpersonal skills, ability to work collaboratively, data management and analytical skills with strong strategic insight, track record of effective project management, and demonstrated ability to build consensus in a physician-driven environment. This role will support the execution of long and short-term goals for the Department of Surgery Q&S program. Because this is a position in an active change management environment, this team member will need to demonstrate flexibility and open-mindedness as the contours of this position will actively evolve over time.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• MGB/MGH quality strategy: Manage high-priority, complex initiatives that support MGB strategic quality priorities, and execute and track department-level performance improvement. Examples of current priorities include improvement of in-hospital survival through hospital and system-wide implementation of the Early Warning and Response System, improved Clinical Documentation Integrity (CDI), and closed-loop follow-up of clinically significant test results

• Department Q&S Committee: Works with Quality Chair to lead and oversee the Dept of Surgery Q&S Committee, which includes Q&S directors across 12 divisions, department leadership, hospital Q&S and nursing leadership, and APP and trainee representatives. Leads agenda planning, slide preparation, meeting facilitation, and meeting follow-up items

• Professional performance evaluation: Collaborate with MGPO and MGB leadership, division chiefs and administrative directors, and analytics team to support department and division OPPE/FPPE processes and ambulatory NRC review, including follow-up of key findings

• MGPO QI Incentive Program: Serve as department liaison for MGPO/MGB QI incentive program. Lead measure development, implementation and tracking for eligible MGPO surgeons

• Process improvement: Attend weekly safety event review meetings, lead process improvement, disseminate best practices, and track immediate and long-term actions for reportable events

• Leads and oversees complex projects spanning multiple divisions and role groups, ensuring timely and successful completion

• Establish 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 lead 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 with analytic strategies to monitor the outcomes of assigned projects.

• Codman Center for Clinical Effectiveness in Surgery (CCCES): Alongside CCCES Medical Director, lead team of data abstractors and work with MGB analytics team to:

• Direct operational aspects of the clinical quality reporting databases and provide divisions with performance data at least twice a year. Support process improvement to address areas of opportunity

• Oversee 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

• Explore AI automation of clinical registry data abstraction, in concert with efforts across other MGB surgical departments, in order to achieve maximum efficiency data collectors

• Prioritize ad hoc division and department data needs

• Coordinate and lead data vendor relationships with internal and external clinical and administrative data repositories

• Education and training: Serve as a resource to department members for process improvement methodologies, data management, analysis, interpretation and reporting

• Work with surgical trainees as they develop, implement, and present their quality improvement work both locally and nationally

• Facilitate department-wide Q&S conferences, including Semi-annual Safety Grand Rounds and Annual Quality Grand Rounds

• Communication: Assist with drafting and dissemination of department-wide communication about key quality and safety risks, current department/MGH/MGB quality improvement initiatives, and research and educational opportunities for trainees and staff

• Strategic planning: Develop and refine the vision for the Department of Surgery Quality & Safety Program and Committee with Executive Director and Quality Chair to ensure programs meet the current and long term needs of the Department of Surgery, MGH, and MGB

• Participate as DoS representative on various department, MGH, and/or MGB work groups. Maintain strong and productive relationships with assigned key stakeholders and customers (Division Q&S Directors, Division Administrative Directors, CCCES Medical Director and Data Abstractors, MGH leadership including Chief Medical Officer and Associate Chief Medical Officer, MGH Director of Quality, MGH Patient Safety and Compliance team, MGB Analytics team, Nursing leadership, etc.)

SKILLS/ABILITIES/COMPETENCIES REQUIRED:

• Demonstrated ability to effectively develop project workplan, meet deadlines and manage multiple highly complex projects within a fast-paced, changing environment

• Demonstrated knowledge and application of quality measurement and process improvement principles, and demonstrated ability to teach/coach/influence/advise staff at all levels, who may or may not have expertise in these areas

• Superior organizational, written, and verbal communication skills, and ability to present data to a wide varied audiences in a clear, concise, and meaningful manner

• Ability to foster trust and collaboration with strong influencing and relationship-building skills

• Experience successfully working with clinical, operational, financial, and other healthcare data, with strong statistical aptitude strongly desired

• Superior skill and experience in MS Office suite (Word, Excel, PowerPoint, Teams, SharePoint); adept at learning new software applications

• Other experience desired: Epic EHR system; Vizient; QI Macros; Tableau

• Knowledge of hospital regulatory reporting requirements desired

• Proficiency in analyzing data and visualization techniques applied in the context of and in support of process improvement efforts

• Change agent demeanor; flexible with demonstrated ability to co-develop creative solutions to complex problems and quickly adapt to a changing environment

• Ability to develop effective relationships with a broad array of people from diverse backgrounds and at all levels in a matrix environment.

• Able to self-manage and make tactical decisions

• High degree of professionalism, discretion, and confidentiality

• Supervisory experience in a healthcare setting preferred

EDUCATION:

Bachelor's degree required; Master's degree in Business, Health Policy, Public Health, or related degree preferred.

EXPERIENCE:

5 years of experience in performance measurement/improvement and/or project management in a hospital setting, preferably in an academic medical center, working with senior level leaders, required.

SUPERVISORY RESPONSIBILITY (if applicable):

Supervises a team of 15 FTEs, which include remote and on-site RN data abstractors and a data analyst

FISCAL RESPONSIBILITY (if applicable):

N/A

WORKING CONDITIONS:

Position will be remote/hybrid. The candidate must be flexible in case of occasional in-person department conferences and meetings.