Job Description

The Chief Quality Officer (CQO) leads hospital-wide quality and performance improvement initiatives to enhance patient care and ensure compliance with regulatory standards, including those from The Joint Commission (JC). The CQO serves as a key liaison between hospital leadership, medical staff, and departments, guiding strategic quality initiatives and maintaining continuous readiness for accreditation and regulatory surveys.

Essential Functions

Directs the development, coordination, and execution of the hospital’s Performance Improvement Plan, ensuring alignment with JC, CMS, and DOH requirements. Serves as the primary liaison for quality improvement among departments, medical staff, and administration. Chairs the Performance Improvement Committee and leads all JC-related activities, including survey readiness, applications, and regulatory correspondence. Provides training and education on performance improvement, patient safety, and regulatory standards (JC, OSHA, CDC). Leads the Joint Commission Task Force to ensure consistent compliance and survey preparedness. Supports medical staff with performance improvement strategies to enhance clinical outcomes. Develops and maintains documentation for all quality activities, ensuring readiness for internal and external reviews. Communicates changes in quality regulations and implements new initiatives across the organization. Serves as a resource and consultant for departments on quality-related concerns and best practices. Reviews and disseminates current research and industry standards to support continuous quality advancement. Performs additional duties as assigned and complies with all organizational policies and standards.

Qualifications

Required:

Bachelor’s degree in Nursing, Healthcare Administration, or a related field 5–7 years of experience in nursing, quality management, or performance improvement 5–7 years of progressive leadership experience in a healthcare setting Knowledge of hospital operations, JC standards, CMS requirements, and DOH regulations

Preferred:

Master’s degree in Public Health, Healthcare Quality, or a related field Clinical nursing experience in an acute care setting Active RN license (state or compact)

Knowledge, Skills & Abilities

Strong understanding of quality improvement strategies and accreditation requirements Excellent leadership, communication, and cross-functional collaboration skills Proficiency in data analysis, performance metrics, and regulatory compliance Commitment to patient safety, clinical excellence, and operational efficiency

What We Offer

Competitive Pay Medical, Dental, Vision, & Life Insurance Generous Paid Time Off (PTO) Extended Illness Bank (EIB) Matching 401(k) Opportunities for Career Advancement Rewards and Recognition Programs Additional Discounts and Perks* *Benefits may vary by role and location.

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