Quality and Safety Data and PI Specialist

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POST DATE 8/31/2016
END DATE 1/27/2017

Massachusetts General Hospital(MGH) Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



The Codman Center for Clinical Effectiveness in Surgery is an academic and service program established by the Department of Surgery to encourage and support surgical outcomes research and continuous quality improvement at MGH. The Codman Center infrastructure is leveraged in several ways, including: advancing the academic careers of surgeons, residents and nurses, assisting surgeons in making informed decisions about the quality of care delivered, determining areas of focus for performance improvement efforts, educating surgeons and residents about surgical outcomes and quality of care, and informing third parties of the quality of care thereby influencing state and national healthcare policy.

Works under general supervision of the Sr. Manager of the Codman Center and Supervising Endocrine Surgeon, and administratively under the direction of the Medical Director of the Codman Center. On a daily basis acquires and enters data into the Endocrine Surgery Database as well as supports the ACS National Surgical Quality Improvement Program. Reviews pertinent data entry points, patient charts, acquire and enter data related to surgical treatment of endocrine, general surgery and vascular surgery patients.

Helps inform, as well as participate in, data ascertainment/abstraction and performance improvement activities focused on surgical quality and safety. Serves as a resource on data management and provide advanced level perspective and support on project development, data initiatives and outcomes research. Conduct sand publishes research independently and in collaboration with clinical leadership.

Leads and participates in performance improvement initiatives across the Department of Surgery. Performs other analytic and reporting tasks, as requested by the clinical or administrative supervisor.


Utilizes extensive knowledge and skill in database development, management and implementation to create, monitor and maintain programs in support of CCCES projects and improvement initiatives.

* Supports National Surgical Quality Improvement Program by providing data entry, 30-day follow up, and retrieval of patient data from hospital proprietary systems..

* As assigned, responsible for reliable collection of preoperative, operative, and postoperative data components for the NSQIP through effective utilization of the hospital medical record system.


* Ensures, by validating proper electronic and paper sources of performed surgeries, that the data for all endocrine surgery cases are captured and reviewed on a weekly basis.

* Incorporates appropriate data from MGH databases such as CPOE, LMR, ACS tumor registry, Thyroid foundation databases and at a national level with the SEER and NSQIP databases.

* Ensures data integrity by:

* Developing and running reports in Access and Excel to verify accuracy of data entered into the database(s) on a weekly, monthly and quarterly basis,

* Reviewing the data fields in the Endocrine database, and continuously update any missing data points,

* Meeting routinely with participating surgeons in order to look at the reliability and the accuracy of the database and to see whether additional information is needed.


* Accurately acquires and processes data into the appropriate database from primary data sources such as the electronic medical record, medical records from external organizations and written office notes

* Develops, creates, provides routine reports to the appropriate members of the Endocrine data team (Supervising Surgeon, and participating surgeons):

* Statistical reports in Access and Excel detailing endocrine surgery to be shared with designated MD members of cytology, pathology, and endocrinology who may require this information for associated projects.

* Ad hoc analyses and primary data outputs at the request of the Supervising Surgeon to be used for research papers originated from the Endocrine Surgery Database.

* Raw data reports for cross checking accuracy of entered data into computerized database(s) by cross checking with other reference databases such as the NSQIP database.

Utilizes knowledge of Epic and application implementations to assist departmental leadership in migrating to Epic, in optimizing use of the system and in creating documentation and tools for use in training and supporting users.

Serves as resource for team members and others on data acquisition, management, utilization and analysis. Participates as a representative of CCCES in meetings and on committees to advance data management and outcomes research with the Department of Surgery and across the Hospital.

Conducts independent and joint research projects on data metrics and methodologies, data management, clinical outcomes and other pertinent topics. Presents findings intra-departmentally and publishes in scientific publications.


* Provides senior level project management support to multidisciplinary teams focusing on high-priority quality and safety initiatives. Serves as the content expert on improvement methodologies and imparts knowledge of improvement process to team leaders and the team. Assists the team in identifying barriers to implementing improvement plans and developing strategy to overcome these barriers.

* Develops the analytic and measurement strategy for all projects undertaken including development of key metrics, identification of data sources and collection of baseline data. The ability to work with quantitative data is a must.

* Communicates regularly with team stakeholders and executive sponsors about team progress toward goal achievement, critical factors and obstacles.

* Oversees project management and logistics such as project timelines, agenda development, production and distribution of meeting minutes and documents and preparation of reports on project status and activities to various audiences.

* Develops project plans that are practical and of appropriate scope, and includes identification of stakeholders, assessment of resource needs, and implementation timelines.

* Works with the Senior Manager and the Quality and Safety Leadership for the Department of Surgery to determine resource/staffing needs for particular project and is accountable for managing the resources and deliverables for specific projects.


* Employs a variety of rigorous improvement methodologies, such as Lean/Toyota Production System, Rapid Cycle Testing, root cause analysis, FMEA, Six Sigma, etc.

* Deployed as staff support to high strategic priority projects as requested by Senior Leadership.

* Engages in training as determined by Department Quality and Safety Leadership

* Bachelors degree required. Masters Degree in Business, Health Policy, Public Health, or related degree preferred.

* 5 years experience in data management or project management/improvement, ideally in healthcare/hospital environment

* Experience with clinical chart review, statistical analyses and preparing clear and concise reports on clinical topics

* Detail-oriented, accurate data ascertainment and data analysis.

* Experience using and teaching about a variety of improvement and redesign tools and techniques such as process mapping, root cause analysis, rapid cycle testing, and/or Toyota Production System/Lean.

* Strong PC skills/Microsoft applications including Word, PowerPoint, Excel, Access, advanced working knowledge of statistical programs

* Ability to lead and work within a team as well as to work independently.

* Excellent organizational skills, ability to manage multiple tasks and