Chief Quality Officer

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 for leading, supporting, and guiding 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's 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.

Hours: Monday-Friday 8:30-4:30 PM, Weekends Off

Please note: Must have a current license as a Registered Nurse in Massachusetts.

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) 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.

MINIMUM ENTRANCE REQUIREMENTS:

Applicants must have at least (A) six (6) years of full-time or, equivalent part-time, professional, administrative, supervisory, or managerial experience in a particular specialty (i.e. scientific, professional, or technical) and must possess current license and/or registration requirements established for the performance of the position, of which (B) at least two (2) years must have been in a project management, supervisory or managerial capacity or (C) any equivalent combination of the required experience and substitutions below:

I. A certificate in a relevant or related field may be substituted for one (1) year of the required (A) experience.

II. A Bachelor’s degree in a related field may be substituted for two (2) years of the required (A) experience.

III. A Graduate degree or higher in a related field may be substituted for three (3) years of the required (A) experience.

IV. A Doctorate in a related field may be substituted for four (4) years of the required (A) experience.

Preferred Qualifications:

• Certification as a Certified Specialist in Healthcare Accreditation (CSHA) and/or Certified Professional in Healthcare Quality (CPHQ) is 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 the 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 in Microsoft Office applications, including Excel, Word, Outlook, PowerPoint, and Teams.

About the Lemuel Shattuck Hospital:

Lemuel Shattuck Hospital is a fully accredited teaching facility by the Joint Commission, providing 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 Corrections and House of Corrections inmates and community patients.

The Shattuck Hospital is at 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 what it’s like to work as a DPH nurse

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

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