Vice Chair of Quality, Assistant Chief Medical Offer- MGB & Spaulding

This leader has the primary responsibility for ensuring execution of the core MGB Office of the Chief Medical Officer (OCMO) functions within the department, including:

• quality and safety
• credentialing and privileging
• provider performance excellence (including oversight of OPPE and FPPE)
• patient experience
• health equity
• professionalism
• clinician well-being

The Vice Chair will work with the PM&R Department Chair, the Spaulding Associate CMO, the AMC CMO and site-based MGB quality teams to oversee daily activities related to these domains and to help implement strategy that is developed by the MGB OCMO. The Vice Chair will represent the AMC CMO and the Spaulding Associate CMO as needed on projects and committees within the department. S/he will function as a clinical leader and advisor on operational issues as they impact the professional staff across the Spaulding Network. By establishing professional and personal credibility with the departmental medical staff, hospital, and Mass General Brigham management, the Vice Chair will establish a tone of leadership which is professional, progressive, equity-informed and outcome- and quality-oriented.

Principal Duties and Responsibilities

General Responsibilities

• Leading advocate for patients and high-quality care across all care settings
• Coordination of departmental quality and safety, clinical compliance, health equity, professionalism and patient experience initiatives and concerns with the AMC CMO, the Spaulding Network Associate CMOs, and with enterprise CMO teams.
• Assist with the development of tracking and reporting for OPPE and FPPE for physicians.
• As appropriate, represents the Department Chair and AMC CMO as needed at various internal leadership meetings as well as to external audiences.
• Communicate proactively with practicing physicians. This will include representing the OCMO and Spaulding at regularly scheduled departmental meetings.
• Support clinical communications across the Spaulding environment related to the above domains.
• Work closely with site-based MGB leaders and broader MGB teams as it relates to quality, safety, infection control, equity, clinical compliance, professionalism, provider well-being and patient experience.

Quality and Safety

• In close collaboration with the Department Chair, AMC CMO and the Chief Quality Officer of MGB, the Vice Chair/Assistant CMO will serve as a visionary leader and champion for patient safety initiatives both within the department and across the enterprise. This leader is responsible and held accountable for promoting, supporting, and leading a culture of safety and quality improvement throughout the organization and for the execution of system and site goals within that department. The Vice Chair/Assistant CMO will work closely with the MGB enterprise Quality and Safety Leadership Teams to align and integrate effectiveness initiatives and patient safety efforts across the organization.
• Support the Department Chair, AMC CMO in presentation of department performance to stakeholder groups.
• Serve as on-site physician executive in support of embedded enterprise team members for clinical compliance, risk management, and patient safety, including conduct of safety event evaluations and mitigation, and Joint Commission surveys and other regulatory site visits and inquiries (DPH, BPHC, etc.).
• Utilize data from safety reports and coordinate with MGB Quality and Safety leadership to analyze trends, identify and prioritize patient safety and quality improvement opportunities, and propose mitigation plans.
• Serve as the department physician executive and liaison to MGB digital for all quality/safety related components of digital build for the department.
• Serve as a physician executive responsible for planning and executing site level-preparedness for surveys at the hospital.
• Represent the department in all efforts associated with regulatory and accreditation bodies.
• Serve as an advisor for physician staff involved in safety events that require disclosure and liaison with hospital risk management.
• Works with the Spaulding Associate CMO, the AMC CMO, and the Spaulding Chief Nursing Officer to establish a culture of High Reliability and to structure and support the HRO clinical units that drive the Patient Care Performance Management (PCPM) platform.
• Work closely with department, hospital and system clinical operations teams as needed to improve on key performance metrics and implement quality improvement initiatives.
• Serve as the accountable leader for improving all quality metrics as defined by the system, Spaulding, or department as being prioritized and having opportunity.
• Support MGB Medical Director for Infection Control in the local implementation of infection control policies in coordination with on-site infection preventionists
• Serve as departmental lead to embedded enterprise hospital quality teams including those supporting Medicare Value Based Purchasing, Hospital Acquired Conditions, and Hospital Readmission Reduction programs.
• Support advancement of ambulatory quality goals in the department in collaboration with MGB CMO and Population Health Management teams
• Assist in implementation of the clinical documentation integrity program for the hospital and serve as the department executive responsible for department performance on initiatives.

Credentialing

• Act as liaison to the MGB Central Credentialing Office (CCO) and departmental leadership to assist and troubleshoot credentialling processes for Spaulding
• Represent the Department Chair and AMC CMO on Medical Staff Credentialing Committees
• Sign off on emergency credentials when required for medical staff.

Patient Experience

• In collaboration with the Department Chair, AMC CMO and the Chief Patient Experience Officer (CPEO), champions, leads and executes the MGB patient experience initiatives within the department. This includes patient experience improvement initiatives as outlined by the CPEO.
• In collaboration with AMC CMO and MGB CPEO, supports the implementation and maintenance of provider transparency. This may include conversations with providers about their ratings and efforts to improve those ratings.
• Serve as department physician executive in support of embedded enterprise team members for patient family relations, facilitate investigations for patient complaints and grievances and supports resolution of these, which may require direct conversation with patients and/or families.
• Ensure that patient complaints that are identified through patient experience surveys are evaluated and handled appropriately within the department and in conjunction with other stakeholders as appropriate (e.g., safety and risk).
• Service as the liaison between the department and OCMO Patient Experience for any questions that arise regarding department patient experience surveying.

Health Equity

• On-site physician executive supporting implementation of system wide health equity activities that align with MGB United Against Racism strategy.
• Coordinate activities within the department in coordination with the MGB Senior Medical Director for Health Equity

Well-Being

• Oversee regular evaluation of well-being in partnership with the CPEO.
• Responsible for assessing well-being data, including drivers, and leading well-being initiatives within the department. This may require additional information gathering from within the department about barriers to professional well-being.
• With departmental leaders, the AMC CMO and CPEO, evaluate and assess what local drivers reduce well-being. For those local barriers, develop a plan to improve clinician well-being.
• Leads and executes the implementation of system initiatives to address provider well-being in the department.

Professionalism

• The Vice Chair of Quality/Assistant CMO will ensure that all members of the department uphold the highest standards of professional conduct as well as minimum proficiency requirements in their discipline, including adherence to MGB medical and human resources policies. Working together with the Department Chair and the AMC Chief Medical Officer, the Vice Chair/Assistant CMO of Quality will steward an environment that fosters a patient-centric atmosphere, that enables a positive culture of safety, that respects and values all individuals, that promotes learning and innovation and is rooted in integrity and equity. In the event of reports of unprofessional conduct, the Vice Chair/Assistant CMO of Quality will collaborate with human resources and the appropriate hospital leaders and departments (including but not limited to the Department Chair, the Chief Medical Officer, the Office of General Counsel, Human Resources, or the Chief Academic Officer) to investigate, document, and redress the inappropriate behavior.

Qualifications and Skills Required

• Strong preference given to candidates with experience within MGB system.
• MD/DO degree with significant combination of clinical and administrative experience in a large academic medical setting and board-certified in specialty.
• Advanced business or healthcare administration degree is desirable but not required.
• A minimum of five (5) years of progressively responsible leadership in hospital setting or large health care organization with proven leadership and management skills.
• Capable of working in an extremely complex academic medical center as part of a large integrated delivery system with many matrixed relationships
• Must be a skilled communicator and team-builder.
• Experience in quality improvement, safety event evaluation, health equity, and patient relations/ service recovery
• Experience in managing local site preparedness and readiness for Joint Commission and other surveys/site visits.
• Exemplary interpersonal communication skills required to interact effectively with senior management and physicians on sensitive political and confidential issues.
• It is expected that this role will take a minimum of 0.4 FTE and will be combined with expected clinical work.

The salary range for this position is estimated to be $300,000 to $400,000 annually. Actual compensation will be determined during the selection process and is based on a variety of factors, including but not limited to relevant experience, education, and internal equity.

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, and bonuses as applicable, designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Physician Recruitment team will provide an overview of your potential compensation and benefits package.