Quality Measure Specialist - Surgical Registries

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Massachusetts General Physicians Organization, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Job Summary The Massachusetts General Hospital is seeking a Quality Measure Specialist with expertise in registry-based quality measurement and a commitment to advancing healthcare performance. This role is essential to supporting high-stakes national registry programs that require precise chart abstraction, certification, and compliance with program standards. The Quality Measure Specialist will manage data abstraction, validation, and reporting for key surgical registries such as the Pediatric National Surgical Quality Improvement Program (Pedi NSQIP), Adult NSQIP, Trauma Registry, Burn Care Quality Platform (BCQP), and Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), among others.

Reporting to the Senior Program Manager of Quality and Safety, the Quality Measure Specialist will be a vital member of a cross-functional team, collaborating closely with clinical, analytics, and information technology teams to ensure accurate registry data submission and compliance. This role also involves analyzing performance metrics, providing actionable insights for clinical leaders, and supporting quality improvement initiatives through robust data interpretation.

Ideal candidates will have strong project management, data abstraction, and analytical skills, as well as an understanding of healthcare quality standards and registry certification requirements.

Qualifications

Principal Duties and Responsibilities:

- Lead the chart abstraction process for various national registries such as the Pediatric and Adult National Surgical Quality Improvement Program (NSQIP),Trauma Registry, Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), Vascular Quality Initiative (VQI), Burn Care Quality Platform (BCQP) , 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.

- 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…