Job Description

The Chief Quality Officer (CQO) is responsible for leading and coordinating quality improvement and performance initiatives throughout the hospital. The CQO ensures compliance with regulatory standards, including The Joint Commission (JC), and serves as a liaison between hospital departments, medical staff, and administration on all quality-related matters. This role oversees the development, implementation, and monitoring of performance improvement plans, ensuring continuous improvement in patient care and operational excellence. 

Essential Functions

Oversees the development, coordination, and implementation of the hospital’s performance improvement plan, ensuring alignment with quality and regulatory standards. Acts as a quality liaison between all hospital departments, medical staff, performance improvement committees, and administration to ensure a cohesive approach to quality improvement initiatives. Chairs the performance improvement committee, leading quality improvement efforts and ensuring compliance with Joint Commission (JC) regulations and other accreditation standards. Serves as the primary contact for all JC-related activities, including surveys, applications, and correspondence, ensuring continuous regulatory compliance. Provides education to hospital staff and medical teams on quality standards, performance improvement methodologies, and regulatory updates. Develops and conducts in-service education programs to enhance staff knowledge of quality improvement and regulatory standards, including OSHA, CDC, and JC requirements. Maintains complete records of all performance improvement activities and ensures accurate documentation for regulatory reviews. Updates hospital staff on changes to regulatory standards and ensures timely communication of new quality initiatives. Acts as a resource to all departments on quality and performance improvement matters, providing guidance and support for quality-related challenges. Leads the JC Task Force to ensure ongoing compliance with regulatory requirements and prepares the hospital for accreditation surveys. Coordinates medical staff performance improvement activities, working closely with clinical teams to enhance patient outcomes. Reviews and disseminates updated information from professional journals, ensuring staff have access to the latest developments in quality and performance improvement. Performs other duties as assigned. Complies with all policies and standards.

Qualifications

Bachelor's Degree in Nursing, Healthcare Administration, or a related field required Master's Degree in Public Health, Healthcare Quality, or related field preferred 5-7 years of direct experience in nursing, quality management, performance improvement, or a related field required 5-7 years of progressive leadership experience in nursing, quality management, performance improvement, or a related field required Working knowledge of general hospital operations, JC standards, CMS requirements, and DOH regulations required 5-7 years of clinical nursing experience at an acute care facility preferred

Knowledge, Skills and Abilities

Strong knowledge of quality improvement methodologies, regulatory compliance, and accreditation standards, including Joint Commission (JC). Excellent leadership and communication skills, with the ability to collaborate across departments and with medical staff. Experience in data analysis, performance metrics, and the development of quality improvement initiatives. Proficient in healthcare regulations and compliance, with a focus on patient safety and performance improvement.

Licenses and Certifications: Required 

RN - Registered Nurse - State Licensure and/or Compact State Licensure Required
 

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