Tewksbury Hospital under the Massachusetts Department of Public Health
Location: Tewksbury, Massachusetts
Type: Full Time
Required Education: 4 Year Degree
Salary: $120,000 to $135,000
This is state government position under the Massachusetts Department of Public Health. Our benefits package also includes medical insurance, dental, vision, life insurance, state pension plan, 12 holidays per year, tuition benefit for employee and spouse at state colleges and universities, wellness programs, professional development opportunities and more.
Telecommuting is allowed.
Internal Number: 220007K6
Tewksbury Hospital, operated by the Massachusetts Department of Public Health (DPH) is seeking an experienced and dynamic professional to serve as the Director of Quality Management. The selected candidate must have experience in hospital quality and risk management and must be a Registered Nurse. The Director of Quality Management 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 Management 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.
Please Note: To meet the Minimum Entrance requirements listed below, the candidates must possess a license as a Registered Nurse in Massachusetts and the required experience must be in the field of hospital quality and risk management.
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.
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 Tewksbury Hospital:
Tewksbury Hospital operates a 370-bed facility and a campus of over 700 acres of land. Its patient care services are provided under the auspices of the Department of Public Health and Mental Health. The Chief Executive Officer (CEO) is responsible for the administration of a Joint Commission accredited LTAC hospital that provides high quality, comprehensive treatment, care, and comfort to adults with chronic medical and mental illness. A full range of services are provided including 24/7 Nursing, Nurse Practitioners, Medicine as well as psychiatric and psychological services, a 6-chair dialysis suite, clinical laboratory, radiology, respiratory care, nutrition, speech/language, pathology, occupational therapy, physical therapy, therapeutic recreation and arts, and pharmacy. The high-quality clinical environment is strictly governed by regulatory standards that mandate day to day interventions and services.
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
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.
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.
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.
Applicants must possess a license as a Registered Nurse in Massachusetts and the required experience must be in the field of hospital quality and risk management.
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.
A certificate in a relevant or related field may be substituted for one (1) year of the required (A) experience.
A Bachelor’s degree in a related field may be substituted for two (2) years of the required (A) experience.
A Graduate degree or higher in a related field may be substituted for three (3) years of the required (A) experience.
A Doctorate degree in a related field may be substituted for four (4) years of the required (A) experience.
About Tewksbury Hospital under the 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 use, violence, preventable hospitalizations, and persistent health inequities.
DPH coordinates programs and policies to address specific diseases and conditions and offers services to address the needs of populations made vulnerable by social and economic conditions. 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 mon...itor 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.