The Lemuel Shattuck Hospital, operated by the Massachusetts Department of Public Health (DPH) is seeking an experienced and skilled professional to serve as the Chief Quality Officer (CQO) for the hospital. The selected candidate must have experience in hospital quality/risk management and must be a Registered Nurse. The CQO is accountable to lead, support and guide the Senior Leadership team in matters related to regulatory requirements, quality, and patient safety. This position will be responsible for building and maintaining collegial and collaborative relationships with Medical Staff, Operational Leaders, and other members of the Public Health Hospital System (PHHS) team.

The CQO reports directly to the Hospital CEO and indirectly to the System Quality Officer and is charged with overall management of the hospital Quality program as part of the overarching PHHS Quality Program and Plan which includes annual quality priorities and goals, risk management and regulatory reporting requirements. The incumbent is the operational leader for the Quality Management Department including oversight of Joint Commission Survey Readiness, Performance Improvement, Clinical Quality, Quality Data Management, Patient Advocacy and HIPAA Privacy.

Duties and Responsibilities (these duties are a general summary and not all inclusive):

• Collaborates with hospital leaders to develop and implement the organization's quality and patient safety plan.
• Oversees the development, review, and revision of the hospital's Quality Improvement Plan.
• Evaluates operational structure and department processes to ensure alignment with effective quality programs.
• Leads the Quality Management department, which includes Infection Prevention and Control, and sets expectations for performance efficiency and effectiveness to achieve goals.
• Chairs and participates in committee meetings pertinent to quality and safety.
• Delegates responsibility and sets expectations for quality management staff, including timely responses to regulatory bodies, including but not limited to, The Joint Commission on Accreditation of Healthcare Organizations (TJC), Centers for Medicaid and Medicare Services (CMS), Department of Public Health (DPH), and Department of Public Health Division of Health Care Quality.
• Coordinates closely with clinical information technology and health information management to achieve organizational goals.
• Partners with hospital leadership and providers to achieve organizational goals, leading root cause analysis (RCAs) and failure modes and effects analyses (FMEAs) analyses and debriefings.
• Recommends quality measures and coordinates the process of monitoring, measuring, and assessing patient care.
• Evaluates regulatory compliance for operational strategies and provides recommendations to maintain compliance.
• Serves as a resource for medical staff, clinicians, and other staff for quality improvement activities and education.
• Promotes a culture of safety, high-reliability, patient and staff engagement, and overall positive work environment for all employees.
• Assesses educational needs for staff and guides quality related education and as appropriate; supports leadership for safety culture surveys.

Preferred Qualifications:

• Master’s degree in a healthcare or relevant field of study.
• Certification as a Certified Specialist in Healthcare Accreditation (CSHA) and/or Certified Professional in Healthcare Quality (CPHQ) desirable.
• Extensive knowledge of regulatory requirements, including those of The Joint Commission, CMS, DPH, and other accrediting bodies.
• Current and up-to-date knowledge of changes to existing laws, standards, and regulations, and the ability to explain and interpret same to facility wide personnel.
• Exceptional research and presentation skills with a talent for engaging a variety of audiences, primarily comprised of adult learners.
• Demonstrated understanding of external agency interface with Infection Control, Patient Safety, Risk Management and Quality (Performance) Improvement.
• High degree of organizational skills and the ability to motivate, coach and supervise staff, to analyze complex problems and issues to design workable solutions.
• Progressive leadership experience in directing a hospital Quality Management Department.
• Strong written and oral communication skills, including methods of general report writing.
• A commitment to promoting a culture of safety, high reliability, and patient-centered care.
• Demonstrated knowledge of process improvement methodologies and team dynamics.
• Technology proficient Microsoft Office applications including Excel, Word, Outlook, PowerPoint, and Teams.

About the Lemuel Shattuck Hospital:

Lemuel Shattuck Hospital is a fully Joint Commission accredited teaching facility that provides acute, subacute, and ambulatory care to patients referred by public agencies and private sector providers. Shattuck Hospital’s services help economically and socially disadvantaged patients to get high quality, cost-effective care from a staff that respects their dignity.

Located in the heart of Boston’s Jamaica Plain neighborhood, the Shattuck Hospital includes 248 inpatient beds including 95 Psychiatric beds and 29 Correctional Health beds. In addition, the Shattuck has a full outpatient clinic with many specialties that offers treatment to patients of the Department of Mental Health as well as Department of Correction and House of Correction inmates and community patients. The Shattuck hospital is on the forefront of substance use disorder treatment including a Suboxone clinic serving 200 patients. In addition to direct medical services LSH hosts and supports an array of services located on the campus, serving patients struggling with addictions and homelessness.

Learn more about Shattuck Hospital: https://www.mass.gov/locations/lemuel-shattuck-hospital

2024 Relocation information: https://www.mass.gov/service-details/dph-renovation-for-shattuck-hospital-replacement-building

Pre-Hire Process:

A tax & background check will be completed on the recommended candidate as required by the regulations set forth by the Human Resources Division prior to the candidate being hired.

Education, licensure and certifications will be verified in accordance with the Human Resources Division’s Hiring Guidelines.

Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth’s website, http://www.mass.gov

If you require assistance with the application/interview process and would like to request an ADA accommodation, please click on the link and complete the Reasonable Accommodation Online Request Form

For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. #2

Comprehensive Benefits

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

Want the specifics? Explore our Employee Benefits and Rewards!