The Lemuel Shattuck Hospital, operated by the Massachusetts Department of Public Health (DPH) is seeking an experienced and dynamic professional to serve as the Director of Quality. The selected candidate must have experience in hospital quality and risk management and must be a Registered Nurse.  The Director of Quality 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 Director of Quality 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 envision, develop, and implement the organization’s quality and patient safety plan.
Ensures compliance with accreditation standards and other regulatory requirements.
Coordinates the Hospital’s compliance with external entities/regulations, 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 the process of monitoring, measuring, and assessing patient care and support of systems to achieve high quality, safe and reliable healthcare services.
Provides data analysis to determine quality and identify trends to manage priorities including developing/implementing dashboards and metrics.
Serves on hospital-wide committees by streamlining operations to the extent possible, to implement solutions to identify trends and patterns such that quality of care for all patients is improved as a result.
Provides direction and serves as a resource to Medical Staff, organization leaders, clinicians, and other staff in various educational settings for quality improvement activities, quality education, and use of quality principles.
Assesses educational needs for staff and guides quality related education and as appropriate
Coordinates closely with clinical information technology and health information management to achieve organizational goals, leading root cause analysis (RCAs) and failure modes and effects analyses (FMEAs) analyses and debriefings.
Delegates responsibility, as appropriate, to Quality Management staff for operational processes such as RCAs, FMEAs, quality surveillance activities and other quality improvement and patient safety strategies.
Establishes and sustains an effective system of communications throughout the hospital; Leads regular team meetings to ensure programs are being executed in accordance with policies and procedures.
Monitors emerging risk factors and methods to track implementation of action plans following site surveys, critical events reviews, communication of quality improvement initiatives, patient safety awareness, safety culture surveys, and patient advocacy.

Preferred Qualifications:

Knowledge commensurate with a master’s degree in a healthcare field.
Registration as a Registered Health Information Administrator (RHIA)
Certification as a Certified Specialist in Healthcare Accreditation (CSHA) and/or Certified Professional in Healthcare Quality (CPHQ) desirable.
Thorough knowledge of Joint Commission Standards and CMS Conditions of Participation.
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.
Demonstrated understanding of external agency interface with Utilization Review, Infection Control, Patient Safety and Quality Improvement.
High degree of organizational skills and the ability to motivate and supervise staff, to analyze complex problems and issues to design workable solutions.
Progressive leadership experience in directing or serving as an assistant director in a hospital Quality Management Department.
Strong written and oral communication skills, including methods of general report writing and proficiency in 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.

Total Compensation:

As an employee of the Commonwealth of Massachusetts you are offered a great career opportunity influencing a wide-spectrum of services to the diverse populations we serve – but it’s more than a paycheck. The State’s total compensation package features an outstanding set of employee benefits which you should consider towards your overall compensation, including:

75% state paid medical insurance premium
Reasonable Dental and Vision Plans
Flexible Spending Account and Dependent Care Assistance programs
Low cost basic and optional life insurance
Retirement Savings: State Employees’ Pension and a Deferred Compensation 457(b) plan
12 paid holidays per year and competitive Sick, Vacation and Personal Time
Tuition Benefit for employee and spouse at state colleges and universities
Short-Term Disability and Extended Illness program participation options
Incentive-based Wellness Programs
Professional Development and Continuing Education opportunities
Qualified Employer for Public Service Student Loan Forgiveness Program
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 Record 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. #2





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


Executive Order #595: As a condition of employment, successful applicants will be required to have received COVID-19 vaccination or an approved exemption as of their start date. Details relating to demonstrating compliance with this requirement will be provided to applicants selected for employment. Applicants who receive an offer of employment who can provide documentation that the vaccine is medically contraindicated or who object to vaccination due to a sincerely held religious belief may make a request for exemption.


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

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About Massachusetts Department of Public Health

The mission of the Massachusetts Department of Public Health (DPH) is to prevent illness, injury, and premature death, to assure access to high quality public health and health care services, and to promote wellness and health equity for all people in the Commonwealth.

We envision a Commonwealth in which all people enjoy optimal health. Massachusetts ranks among the healthiest of states according to comparative analyses, but we face numerous challenges, including chronic and infectious disease, substance abuse, violence, preventable hospitalizations, and health disparities.

DPH coordinates programs and policies to address specific diseases and conditions and offer services to address the needs of vulnerable populations. We also develop, implement, promote, and enforce regulations and policies to assure that the conditions under which people live are most conducive to health and enable people to make healthy choices for themselves and their families. We license health professionals, healthcare facilities and a variety of businesses that impact public health. We operate the state laboratory and four public health hospitals. We monitor health status and manage vital records including births, marriages and deaths. We educate people about public health issues and work closely with local boards of health and community partners to identify and solve public health problems.