Quality Improvement Manager & the Joint Commission Survey Coordinator @ Beth Israel Lahey Health

Medical, Clinical & Veterinary (1)

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

40hpw; Day Shift; Monday- Friday

Job Description:

Key Responsibilities

Assists the Director in developing and executing strategic plans related to quality and safety improvement initiatives.
Establishes project timelines, priorities, and action plans; monitors outcomes to ensure alignment with organizational goals.
Oversees administrative responsibilities, including the development of the annual budget and management of timekeeping systems (e.g., Kronos).
Provides education in data analysis to staff and PI teams, promoting data literacy across the organization.

Leading the design, execution, and evaluation of data-driven QI projects aligned with organizational priorities
Facilitating cross-functional teams to identify performance gaps and implement evidence-based improvements
Monitoring, analyzing, and reporting key quality and patient safety indicators to leadership
Supporting departments in using quality improvement tools and methodologies (e.g., PDSA, Lean, Six Sigma, IHI model for improvement, 7 Step improvement framework etc.)
Assisting with root cause analyses (RCAs) and failure mode and effects analyses (FMEAs) to drive process improvement and enhance patient safety
Utilizes evidence-based tools to develop and maintain statistical processes, control charts, and databases to support quality improvement and performance tracking.
Analyzes data to identify patterns, trends, and opportunities for improvement.
Prepares and disseminates reports, dashboards, and scorecards—including the Quality Scorecard to support organizational and departmental performance monitoring.
Acts as administrator and primary resource for Q-Net, ensuring compliance with IPPS, OPPS, and PQRS reporting requirements, and communicates updates to leadership.

Ensures compliance with all regulatory and accreditation standards, including those from CMS, The Joint Commission (TJC), the Department of Public Health (DPH), and other relevant agencies.
Leads and manages accreditation and re-accreditation activities, including TJC survey readiness, application submissions, Evidence of Standards Compliance (ESC), and Measures of Success (MOS).
Maintains continuous survey readiness and oversees all aspects of regulatory compliance, deadlines, and reporting requirements.
Oversees the integrity and management of clinical indicator databases, ensuring accurate and timely internal and external data reporting.
Coordinates the collection, analysis, and submission of publicly reported and outcome data, including ORYX, CMS-VBP, PSO metrics, Meaningful Use, DPH reports, HCAHPS, and NDNQI.
Submits required external reports and surveys, including Leapfrog, MassHealth, Stroke GWTG, Core Measures, BCBSMA, and HPHC.
Applies basic biostatistical analysis to monitor performance trends and inform quality improvement and pay-for-performance initiatives.
Identifies and corrects data inaccuracies to ensure data integrity and compliance.
Collaborates with Information Technology to develop and maintain secure, efficient data systems and extraction processes.
Maintains strict confidentiality when handling sensitive patient and organizational data.
Provides analytical support for quality improvement, regulatory, and value-based care initiatives.

Serves as a direct supervisor, professional role model and mentor to RN Quality Coordinators.
Collaborates with clinical managers, physicians, leadership, and Quality Coordinators to implement and evaluate quality initiatives.
Contributes to the performance evaluations of Quality Improvement Specialists and provides input to the Peer Review and Quality Improvement Manager.

Coordinates key culture initiatives, including TeamSTEPPS, culture of safety assessments, and leadership walkrounds.
Implements a service excellence program and monitors progress using HCAHPS data.

Develops and delivers educational programs for nursing and clinical staff to support compliance with quality measures.
Designs and implements user training for clinical information systems, in collaboration with the Peer Review and Quality Improvement Manager.

Experience/Knowledge/Skills:

Minimum of five years of experience in a healthcare organization, with direct work involving CMS and The Joint Commission core measure data set with demonstrated progressive supervisory or leadership experience.
Ability to utilize LEAN methodology to lead and support process improvement initiatives aimed at reducing waste, enhancing efficiency, and improving patient outcomes.
Proficient in navigating Windows-based environments and electronic medical record systems.

Ability to prepare high-quality, finalized reports for review by the Director of Quality and Safety.
Exceptional organizational skills with strong attention to detail.
Proven ability to manage multiple priorities, meet tight deadlines, and work efficiently in a fast-paced environment.
Excellent written and verbal communication skills.
Strong analytical, problem-solving, and presentation abilities.

Education and Experience:

Bachelor’s degree in a healthcare-related field required; Master’s degree preferred
Current Massachusetts healthcare professional license preferred (e.g., RN, NP, PA, or another relevant licensure)
Certified Professional in Healthcare Quality (CPHQ) strongly preferred, or must be obtained within one year of employment

Quality Improvement Manager & the Joint Commission Survey Coordinator