Job Description

Overview

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). The selected candidate must have experience in hospital quality/risk management and must be a Registered Nurse (RN) with a current license in Massachusetts. The CQO leads and guides the Senior Leadership team on regulatory requirements, quality, and patient safety, and builds collaborative relationships with Medical Staff, Operational Leaders, and the Public Health Hospital System (PHHS) team.

The CQO reports to the Hospital CEO and to the System Quality Officer and manages the hospital Quality program as part of the PHHS Quality Program and Plan, including annual quality priorities, risk management, and regulatory reporting. 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.

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

Duties and Responsibilities

• Collaborates with hospital leaders to develop and implement the organizations quality and patient safety plan.
• Oversees the development, review, and revision of the hospitals Quality Improvement Plan.
• Evaluates operational structure and department processes to ensure alignment with effective quality programs.
• Leads the Quality Management department, including 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 such as The Joint Commission, CMS, DPH, and related divisions.
• 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 analyses (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 an overall positive work environment for all employees.
• Assesses educational needs for staff and guides quality-related education; supports leadership for safety culture surveys.

Qualifications

Minimum Entrances Requirements:

Applicants must have at least six (6) years of full-time or equivalent part-time professional, administrative, supervisory, or managerial experience in a related field and must possess current license/registration requirements. At least two (2) years must have been in a project management, supervisory, or managerial capacity. Substitutions are allowed as described below.

Substitutions:

• I. A certificate in a relevant field may substitute for one (1) year of required experience.
• II. A Bachelors degree may substitute for two (2) years of required experience.
• III. A Graduate degree or higher may substitute for three (3) years of required experience.
• IV. A Doctorate degree may substitute for four (4) years of required experience.

Salary placement considers experience and education and alignment with the Human Resources Divisions Hiring Guidelines. For bargaining unit positions, compensation follows the applicable collective bargaining agreement.

Other Information

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits. This role requires compliance with Title 101 CMR 23.00, which includes vaccination requirements or mitigations; successful candidates will attest to vaccination status for COVID-19 and Influenza.

Equal Opportunity Employer: The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by law. We encourage applicants who meet the skills to apply.

Official Title: Program Manager Specialist VII

Location and Scheduling

Primary Location : Administrative Services, Department of Public Health

Schedule : Full-time

Shift : Day

Number of Openings : 1

Salary : 100,839.08 - 155,529.95 Yearly

Contact

If you have Diversity, Affirmative Action or Equal Employment Opportunity questions or need a Reasonable Accommodation, please contact Diversity Officer / ADA Coordinator: Sandra.C.Semedo@mass.gov / Stacy.Hart@mass.gov 617-352-4250

Bargaining Unit : M99-Managers (EXE)

Confidential : No

Potentially Eligible for a Hybrid Work Schedule : No

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