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.

• 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.
• Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas which are at risk.
• Provides strong bi-directional communication between the system and the site, with accountability for distribution of organization communication (including pertinent data and analytics) from MGB to SRN and vice versa.
• Manges the department budget effectively and determines fiscal requirements and prepares budgetary recommendations.
• Performs staff performance evaluations establishing a development plan for each employee.
• Performs other duties as assigned.
• Direct oversight of 3-5 quality performance and improvement staff

Knowledge, Skills, and Experience Required

• Demonstrated knowledge and application of principles of quality measurement, governmental and regulatory quality requirements, process improvement, particularly as it relates to physical medicine and rehabilitation. Demonstrated knowledge and competence in executing and sustaining improvements in clinical care, as well as holding themselves and other stakeholders accountable to sustaining improvement over time. Ability to proficiently explain these domains to others, who may or may not have expertise within rigorous quality improvement.
• Demonstrated ability to successfully lead a local quality performance and improvement team, as well as demonstrated competence and knowledge in clinical care which allows them to partner with departments to achieve key objectives.
• Strong background and skill in implementation science, and the ability to move from measuring a problem to correction of the problem with an eye towards sustainability and accountability.
• Ability to balance the need for collaboration vs the need to make executive decisions quickly and reliably.
• Knowledge of requirements for maintaining regulatory accreditation and standards compliance throughout diverse and specialized areas that are relevant to a specialty care hospital.
• Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements; problem assessment and problem-solving techniques; health care law; health care services.