Quality Measure Specialist

Principal Duties and Responsibilities:

- Lead the chart abstraction process for the Burn Care Quality Platform (BCQP) and support (as needed) various national registries such as the Trauma Registry, Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), Vascular Quality Initiative (VQI), Adult and Pediatric National Surgical Quality Improvement Program (NSQIP), and the Commission on Cancer (CoC), ensuring a high degree of accuracy and compliance with registry-specific requirements.

- Manage data submission and validation for registry participation, including the preparation and transmission of data files according to each registry's specifications and timelines.

- Monitor registry performance metrics and analyze outcomes data to identify trends, areas for improvement, and opportunities to enhance patient care quality within the organization.

- Collaborate with clinical teams and department leaders to interpret registry data, provide insights on performance measures, and develop action plans for quality improvement initiatives based on registry findings.

- Participate in regular committee meetings (often quarterly) with clinical teams to review registry performance data, discuss findings, and collaboratively identify areas for improvement. Ensure that performance metrics align with registry standards and support the hospital's ongoing quality improvement initiatives.

- Stay current with registry updates and changes, including modifications to data elements, abstraction guidelines, and certification requirements, and communicate these changes to relevant stakeholders.

- Ensure ongoing compliance with certification and recertification requirements for relevant registries, including scheduling and preparing for certification exams and maintaining necessary documentation.

- Serve as the primary representative for burn registry-related accreditation site visits, demonstrating a comprehensive understanding of registry standards, data abstraction processes, and performance outcomes. Support hospital accreditation efforts by preparing documentation, presenting data, and addressing inquiries from the accrediting body during onsite evaluations every 2-3 years.

- Coordinate with Information Technology and Electronic Health Record (EHR) teams to optimize data extraction processes, improve data quality, and streamline abstraction workflows.

- Prepare and present detailed reports and presentations summarizing registry data, performance outcomes, and recommendations to leadership, clinical staff, and external partners in various formats (narrative summaries, slides, graphs, tables).

- Utilize Mass General Brigham values to guide decisions, actions, and behaviors, embodying principles such as Patient-Centered Care, Accountability, Innovation, Diversity & Inclusion, Integrity & Respect, Continuous Improvement, and Teamwork & Collaboration.

- Other duties and responsibilities as assigned, contributing to the overall success of the Department of Surgery Quality and Safety Team and supporting organizational goals.

Qualifications

• Bachelor's or master's degree in business, Health Policy, Public Health, or related degree preferred

• Clinical licensure (RN, NP, PA) preferred.

• Commitment to ongoing certification maintenance, including annual recertification exams, as required by specific registries to ensure compliance with national standards.

• 1+ years of experience in healthcare quality measurement, analytics, chart abstraction

• 1+ years of experience in project management or improvement

• Proficient with Epic Workbench Reporting and navigating Epic for chart review.

• Proficiency with Snowflake, SQL, or other analysis language a plus

• Clinical experience specifically within the burn division is a plus

• Strong PC skills/Microsoft applications including Word, Powerpoint, Excel are required.

Skills/Abilities/Competencies

• Ability to function effectively and independently in a fast-paced environment, organize and prioritize work independently, and meet tight deadlines

• Ability to manage multiple projects/registries simultaneously, set priorities, and collaborate with team members and others throughout the organization

• Possess strong interpersonal skills to effectively communicate with cross functional teams including staff at all levels of the organization

• Practical problem-solving abilities, i.e. the ability to formulate hypotheses, test options and move forward in a fast-paced environment

• Ability to coach/teach others about complex quality measures in various registries

• Excellent interpersonal skills, including strong customer service orientation and the ability to translate complex technical concepts to non-technical audiences.

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.