Site: Brigham and Women's Faulkner Hospital, Inc.
Job SummaryThe Senior Manager, Quality and Safety is responsible for leading the local execution of Mass General Brigham Community Division strategy, infrastructure, processes, and performance improvement efforts across patient safety, risk management, quality, and clinical compliance.
This role oversees and supports the implementation of standardized best practices, safety and quality programs, regulatory readiness activities, and performance improvement initiatives that advance safe, reliable, high-quality care.
The Senior Manager serves as a key local administrative leader and partners closely with system and site leadership, clinical teams, the local ACMO, risk/safety leaders, infection prevention, compliance, legal, data and analytics teams, and other stakeholders to execute both short- and long-term goals for Quality, Patient Safety, Risk Management, and Clinical Compliance programs.
This position is responsible for translating system strategy into local execution while also providing strong bidirectional communication between the site and system teams regarding local risks, emerging trends, operational needs, performance gaps, and improvement opportunities.
Because this is a leadership role in an active change-management environment, the Senior Manager must demonstrate flexibility, sound judgment, collaboration, and openness as the scope and needs of the role continue to evolve over time.
QualificationsQuality, Safety, and Risk Strategy Execution- Execute MGB Community Division strategy for patient safety, risk management, quality, and clinical compliance at the local site, ensuring alignment with standardized system processes, priorities, policies, and performance expectations.
- Support the buildout of local safety, quality, risk, and compliance infrastructure, including standardization in training, workflows, governance, reporting structures, and response processes that are in line with MGB.
- Collaborate with system and site leadership to execute long- and short-term goals for Quality, Patient Safety, Risk Management, and Clinical Compliance programs.
- Provide essential input to MGB leadership regarding strategy, infrastructure, policy development, performance improvement plans, and local operational needs to support high-quality care delivery.
Patient Safety and Risk Management- Execute MGB patient safety plans, including safety event reporting, event analysis, mitigation planning, and follow-up on safety-related concerns.
- Implement standardized risk management strategies, policies, and procedures, ensuring that risk management activities align with and strengthen the organization's approach to patient safety.
- Implement and support use of the systemwide safety event reporting system.
- Support systemwide and local safety events, including recalls, shortages, and other issues that may impact patient safety.
- Partner with site Risk/Safety/PFR leaders and clinical teams to develop prospective solutions and performance improvement actions in response to safety events.
- Leads the development and delivery of patient safety and risk management training using culture-of-safety data, safety event trends, and systemwide priorities to promote continuous improvement, staff engagement, and safe, reliable care practices across all departments.
- Completes, within three (3) months of hire, High Reliability Organization (HRO) training, including Level 3, Fact Gatherer, and Process Facilitator, and integrates HRO principles into oversight of safety event analysis, improvement strategy, and organizational learning.
Quality Performance and Improvement- Serve as the local administrative leader responsible for executing quality performance and improvement programs at the site.
- Ensure adherence to MGB standardized processes for quality measurement, prioritized quality goals, quality strategy, and performance improvement activities.
- Provide proactive and reactive quality performance improvement planning in partnership with local clinical teams, department leaders, and floor-based teams.
- Lead the planning, implementation, and evaluation of process changes and performance improvement activities.
- Effectively communicate goals, strategic priorities, accountability expectations, and improvement plans to clinicians and operational leaders, engaging them as partners in achieving quality and safety outcomes.
- Serve as the senior local site manager responsible for Quality Assurance and Performance Improvement (QAPI) planning, documentation, and updates for board quality committee and/or patient care assessment committee needs.
Clinical Compliance and Regulatory Readiness- Serve as the senior local administrative manager responsible for clinical compliance activities, including tracer activity, site preparedness, monitoring, and adherence to standardized compliance processes.
- Build and support the local implementation of the MGB clinical compliance program, ensuring standardized processes, staff training, procedures, and governance are in place.
- Monitor institutional compliance with Joint Commission standards and other applicable regulations, and advise system leadership regarding areas requiring improvement.
- Lead or support proactive and reactive clinical compliance activities, including risk assessments, improvement plans, regulatory interpretation, and implementation of needed process changes.
- Serve as the senior clinical compliance manager responsible for management and performance during expected and unexpected regulatory visits, including but not limited to The Joint Commission, DPH, DMH, and CMS.
- Oversee submission of required documentation and reports to relevant accrediting and regulatory bodies, including DPH, DMH, TJC, BORIM, and MedSUN, and complete submissions directly when front-line support is not available.
- Liaise with system and site teams, clinicians, corporate compliance, and the Office of General Counsel regarding compliance issues, regulatory requirements, site visits, and areas of overlap.
Data, Analytics, Reporting, and Dashboards- Partner with MGB data and analytics teams to ensure reporting to CMS, other regulatory bodies, private payer contracting entities, external benchmarking organizations, and quality/safety reporting programs is timely and accurate.
- Understand data provided by system teams and use knowledge of local practices and culture to identify opportunities for improvement, emerging risks, and areas requiring local or system-level attention.
- Advise in the development of local and system-level dashboards related to quality performance, clinical compliance, patient safety, and improvement priorities.
- Analyze trends and emerging risks, communicate findings to local teams and system leaders, and support improvement planning based on available data.
- Prepare reports and presentations as needed for site leadership, system leadership, regulatory bodies, committees, and other stakeholders.
Collaboration and Local Leadership- Partner with the local ACMO and clinical teams to implement system goals, site-level improvements, and accountability processes.
- Liaise with infection prevention and control teams to monitor performance, respond to data, and support actions to reduce risk of infections to patients.
- Maintain strong organizational relationships and work effectively within a matrixed healthcare environment.
- Provide strong bidirectional communication between the system and site, including distribution of pertinent data, analytics, priorities, concerns, and operational feedback.
- Ensure recommended improvements are implemented and partner with local leadership to support accountability.
Staff Management and Department Operations- Manage, supervise, and support assigned quality, safety, risk, and/or compliance staff, including recruitment, interviewing, training, orientation, remediation, and performance evaluation.
- Establish development plans for staff and support ongoing professional growth, role clarity, and accountability.
- Manage departmental operations and budget responsibilities as assigned, including fiscal planning and budgetary recommendations.
- Oversee local training and educational programs related to quality, safety, risk, and clinical compliance as needed.
- Perform all other duties as assigned and requested.
Additional Job Details (if applicable)QualificationsEducation- Bachelor's degree required in a related field.
- Master's degree preferred in Nursing, Public Health, Business Administration, Public Administration, Health Services Administration, Patient Safety Leadership, or a related field.
Experience- Minimum of 5 years of experience in quality, clinical compliance, patient safety, risk management, performance improvement, or a related healthcare leadership function required.
- Minimum of 3-5 years of experience managing teams required.
- Experience working in a large, matrixed healthcare organization preferred.
Skills and Competencies- Strong leadership, collaboration, and relationship-building skills in a matrixed healthcare environment.
- Demonstrated ability to lead change, support standardization, and implement system strategy at the local level.
- Strong verbal and written communication, presentation, project management, and process improvement skills.
- Ability to use data, analytics, local knowledge, and performance trends to identify risks, improvement opportunities, and areas requiring escalation.
- Ability to effectively and persuasively communicate goals, expectations, accountability processes, and improvement plans to clinical and operational partners.
- Advanced knowledge of Microsoft Office products, including Word, Excel, PowerPoint, and Access.
Remote TypeHybrid
Work Location1153 Centre Street
Scheduled Weekly Hours40
Employee TypeRegular
Work ShiftDay (United States of America)
Pay Range$99,465.60 - $144,643.20/Annual
Grade8
At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
