Quality - Baystate Health

Req#: R16052
Category(s): Performance/Analytics/Quality, Quality
Full Time / Part Time: Full-Time
Shift: First


This position oversees the development and ongoing management of serviceline performance improvement.

Responsible for data abstraction, analysis, and presentation of clinical outcomes to serviceline PI committee and development/submission of biannual quality reports to senoir management. Work with nursing and clinical departments within the serviceline to develop, design and monitor systems to improve clinical care, crafting unit specific report cards. Partner with DHQ, risk management, guest relations and clinical teams to coordinate clinical concerns and lead teams in resolution of issues. Responsible for designing/ collecting and submitting data to external regulatory and societal agencies based on time sensitive deadlines. Responsible for developing report cards that correlate quality and cost by case. Responsible for overseeing current/future research and partners with physicians/IRB to submit proposals that meet regulatory requirements and grow academic aspect of serviceline. Participate on Model of Care teams and assist in designing population specific clinical care models across the region. Will work to quantify and measure performance success. Will be the identified contact for JCAHO, DPH and other regulatory agencies for the service line working with the managers to ensure all issues are identified and resolved. Responsible for leading initiatives around population specific accreditation. (e.g. stroke, VAD).
Manages clinical RN coordinators and/or outcomes coordinators. Assumes leadership role in designing and executing yearly regional serviceline educational symposiums

Job Responsibilities: 

1) Structures and manages department personnel, ensuring timely and accurate collection of clinical outcome data, exceptional staff performance and teamwork. Ensures thorough and accurate submission of data to regulatory agencies, National and State databases for comparative reporting.

2) Takes leadership role in working with managers, physicians and clinicians to design and implement projects and programs to correct population specific quality deficiencies. Develops and delivers formal presentations to department and service line and hospital leaders regarding population based clinical outcomes and outlining action plans for improvement.

3) Creates service line dashboards and works in partnership with DHQ to develop annual outcomes report that is distributed to key regional markets. Partners with Dept of Health Care Quality, IT and department and/or service line model of care teams to ensure implementation of evidenced based standards, population based order sets and outcomes tracking and reporting of new programs

4) Works with departmental/nursing managers to develop specific quality dashboards and action plans.

5) Represents departments and service line in taking the lead to ensure JCAHO compliance in all departments.

6) Represents the departments and service line at external conferences and events. Prepares data and information for submission and/or presentation.

7) Partners with physicians, clinicians, residents and fellows in data collection and presentation for publication and research

8) Oversees the education coordinator position. Ensures program goals are developed and executed for any fellowship aspects of this position as well as the department and/or service-line educational programs that this position supports

9) Oversee the manager of research for the program. Ensure program goals are developed and executed for research done throughout department and/or service-line.

10) Evaluate and implement cross functional data collection and registry information between Outcomes and research departments.

Required Work Experience: 

1) 3-5 years experience clinical; 2-4 years experience in health care data coordination, health care organization activities and interaction with physicians and staff in administrative capacity

2)  Successful experience in independent project management

Preferred Work Experience: 

1) Experience with data and outcomes analysis preferred

Skills and Competencies: 

1) Must have excellent understanding of the principles surrounding performance improvement, lean theory, quality of care, outcomes measurement and analysis and health care cost measurement and containment

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Bachelor of Science: Nursing (Required), Master of Arts


Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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