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Chief Quality/Safety Officer

NH-United States-Dover Apply View Saved Jobs Job ID 3146745 Date posted 06/11/2021
Chief Quality/Safety Officer -(3146745)


The Chief Patient Safety and Quality Officer (CPSQO), working in partnership with Wentworth-Douglass Hospital (WDH) administrative and medical staff leadership and in collaboration with Massachusetts General Hospital (MGH) and Mass General Brigham (MGB), provides leadership in the development of a culture of safety and the measurement of the quality of care identifying opportunities and strategies for performance improvement (PI).

The CPSQO reports to the WDH Chief Physician Executive (CPE), serves as a member of the Executive Team, collaborates with executive leaders, medical staff leaders, and the Senior Vice President Quality and Safety Officer MGH, to achieve system wide quality of safety goals.

Position Purpose:

To direct Healthcare System wide quality improvement efforts with particular regard to performance measures defined by governmental, accrediting and public reporting entities, as well as internal measures of interest.

Continuously improve safety throughout the system by reducing the risk of patient, staff, and visitor harm.

Promote a culture of safety throughout the system.

Primary Accountabilities:  Quality Functions

Initiates and oversees the development of a comprehensive safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives.

Directs system wide clinical quality improvement activities, particularly those relating to measures of interest to government programs, including but not limited to CMS, FEP, Medicaid, and other accrediting and public reporting bodies.

In conjunction with the Medical Staff and system leadership, directs and coordinates safety/quality/ and performance improvement initiatives.

Provides medical expertise and collaboration for all Disease Management, Quality, Pharmacy, Care Management, and Medical Review initiatives.

In collaboration with clinical staff, department chairs, service line leaders and the CMO of Wentworth Health Partners, participates in monitoring, reporting, and improvement activities related to clinical guidelines, health care quality/safety initiatives, and accreditation and regulatory requirements.

Supports collaborative relationships with physicians and hospital.

Fosters and maintains collaborative relationships with WDH, MGH and MGB and with external agencies, purchasers, and stakeholders related to quality/performance initiatives.

Collaborates with and serves as liaison to the Senior Vice President of Quality and Safety MGH.  Participates in jointly sponsored programs to drive performance improvement.

Creates, reviews, and amends medical decision-making policies as they relate to quality and safety, and reviews and recommends criteria as appropriate.

Provides overall direction to ensure that clinical services are provided in accordance with evidence based quality and safety standards and those established via state and federal regulations, collaborates with Senior Director of Risk and Survey Readiness to assure compliance with The Joint Commission accreditation standards, including the National Patient Safety Goals.

Assesses entity compliance with accreditation standards and regulations related to clinical care in collaboration with entity leadership and staff.  Identifies areas of vulnerability and directs the development of strategies to enhance compliance.

Participates in Medical Management strategic planning in evaluating utilization, quality, national and local trends, and identify interventions to optimize the utilization of resources and the delivery of high quality health care services


Provides strategic oversight for patient safety and quality related committees with accountability for distribution of organizational communication vertically and horizontally within WDH system as appropriate.

Assists in the development of strategic opportunities to control cost and increase quality and safety, particularly relating to the components of Value Based Purchasing

Proactively educates leadership, physicians and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/PI activities using various formats.

Regularly communicates PI and quality/safety activities to leadership and staff.

Works closely with other Medical Directors, Director of Ml Quality Improvement, Director of Pharmacy, Medical Directors of Physician Networks and all other departments and divisions.

Fosters and maintains collaborative relationships Northeast Healthcare Quality Foundation and other external agencies, purchasers, and stakeholders related to quality/performance initiatives.

Manages the departmental budget effectively and determines fiscal requirements and prepares budgetary recommendations.

Performs staff performance evaluations establishing a development plan for each employee.  Performs other related duties incidental to the work described herein.

Responsibilities:  Safety Functions

Conducts regular Safety Team Walk Rounds.

Provides education about Clinical Safety.

Participates in the analysis of Culture of Safety Surveys.

Organizes occurrence safety related reporting data according to Joint Commission Standards chapters.

Performs annual safety risk assessment based on quality data, culture of safety data, and occurrence reports to identify areas of focus for improvement.

Drafts annual plan for safety improvement based on risk assessment.

Identifies safety trends or issues based on occurrence reports and other data, categorized by applicable JC Chapters (NPSG’s, Provision of Care, Med Management, Performance Improvement) that may require attention in the interim between annual risk assessment.

Assist in implementation of plans for safety improvements.

Provides strategic oversight of proactive and reactive patient safety activities including root cause analyses, failure mode effects analyses and Sentinel Event Alerts in regards to the facilitation of process, planning, implementation and evaluation of effectiveness of process changes.

Review and analyze safety and quality data and assist in developing plans for improvement for presentation to Performance Improvement Committee (PIC).

Collaborates with and serves as liaison to the Senior Vice President of Quality and Safety MGH.  Participates in jointly sponsored programs to reduce patient and workforce harm.

In collaboration with risk management, take advantage of the offerings of CRICO RMF to ensure patient safety approaches are maintained and new opportunities explored and adopted as necessary

 Oversees Infection Prevention Program (IP)

Director of IP directly reports to the CQSO

The CQSO assists the Director of Infection Prevention in developing IP strategies.

The CQSO provides support to, and oversight of, the WDH System Infection Prevention program


Qualifications - External

Required Qualifications at this Level

Education:                               M.D./D.O.


Experience:                             A minimum of 5 years of direct patient care experience as a

                                                Healthcare professional.  A minimum of 3 years in

accreditation/regulatory affairs/performance improvement/patient

safety in healthcare.


Degrees, Licensure, and/or a master’s degree in a healthcare field.



Knowledge, Skills, and           Knolwedge of accreditation standards, health care regulations,

Abilities:                                  performance improvement, patient safety and policy formulation.

Effective organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.

Ability to work with a variety of disciplines and levels of staff across departments and the health system is required.

EEO Statement

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c) 

Primary Location

:NH-Dover-WDH Main Hospital

Work Locations

WDH Main Hospital
789 Central Ave




:Wentworth-Douglass Hospital(WDH)


Standard Hours:32


:Day Job

Employee Status

Recruiting Department:WDH Quality

Job Posting

:Jun 10, 2021


"The best thing about my job at Wentworth-Douglass is my co-workers; they are like family and I genuinely love to come to work!"

Environmental Services Staff


"I chose to come to WDH for many reasons: the location, the friendliness, and the welcoming environment I was surrounded with when I first entered. Walking into WDH you immediately feel at ease. It's like you aren't even in a hospital; it's clean, calming, and everyone is so friendly and welcoming. My department is a constant learning experience due to the need of radiology throughout the hospital. Anyone thinking of working here…DO IT! You won't regret it. If you're looking for an incredible job, full of wonderful experiences and great staff, don't hold yourself back. "

Registered Nurse


"When I began at WDH I was amazed at the technology and access to resources that are available to me which supports my day to day job function enabling me to be accurate, efficient and collect supportive data to make a difference for the future of the hospital, physicians, staff and our patients. Since being at WDH I have vastly built on my skill set as a Case Manager thanks to the expertise of the physician advisors, my manager and team of seasoned, expert Case Managers. WDH offers, encourages and supports professional growth with a strong team atmosphere. I have been encouraged to become involved in committees that promote positive change within my team. I feel I have a voice and can make a difference for the better.
My career as a Registered Nurse has become a lot clearer since joining my WDH team. I would say to anyone looking to advance his or her career, feel supported and belong to an awesome organization has a commitment to their community health; WDH is the place for you. "

Case Manager


"I chose to come to WDH because of its reputation. I had always heard such great things about the hospital and the staff. Coming here, I have found the teamwork is what I have enjoyed most; the staff have been so welcoming and have treated me like family. I love my job and the management is by far the best I have ever experienced. Anyone thinking of applying to WDH should definitely do it!"

ED Tech


"I did not know what I wanted to pursue as a career, but I knew I wanted to be in the medical field. I took a Phlebotomy course to get my foot in the door and got hired at WDH. Ten years later, I am still here and loving it every day. Not only do I love my coworkers, who have become my close friends, but I love the diversity of my job. Often times I feel people overlook what we do, but not only do we provide compassion and skill in our job to the patients, but we also get to see behind the scenes; working closely with the medical staff ensuring patients are getting accurate results. I feel rewarded at the end of everyday knowing that I have played a role in helping the patients get the proper treatment they need."



- Awards and Recognitions -

Magnet Recognized Logo

Magnet Recognition Program®

Wentworth-Douglass Hospital has achieved Magnet® recognition, the nation’s highest honor for excellence in nursing, recognizing professionalism, teamwork and superiority in patient care.

More Awards & Accreditations

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