Job Description

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.

Hours: Monday-Friday 8:30-4:30PM, 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) 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:

• 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: what it’s like to work as a DPH nurse

Learn more about Shattuck Hospital:

Relocation information :

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 before the candidate is 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,

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. #4

Qualifications

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.

Substitutions:

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

Salary placement is determined by a combination of factors, including the candidate’s years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division’s Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range

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!

Title 101 CMR 23.00 (“Regulation”) requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

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 appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.

Official Title : Program Manager Specialist VII

Primary Location : United States-Massachusetts-Boston-170 Morton Street

Job : Administrative Services

Agency : Department of Public Health

Schedule : Full-time

Shift : Day

Job Posting : Apr 7, 2025, 2:59:53 PM

Number of Openings : 1

Salary : 98,861.85 - 152,480.35 Yearly

If you have Diversity, Affirmative Action or Equal Employment Opportunity questions or need a Reasonable Accommodation, please contact Diversity Officer / ADA Coordinator : Luciana.M.Hayner@mass.gov / stacy.hart@mass.gov - 8573981891

Bargaining Unit : M99-Managers (EXE)

Confidential : No

Potentially Eligible for a Hybrid Work Schedule : No

Job Tags

Full time, Part time, Work experience placement, Relocation, Shift work, Monday to Friday,

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