Job Summary:
The Chief Quality Officer (CQO) leads hospital-wide quality improvement and performance initiatives to enhance patient care and operational excellence. This role ensures compliance with regulatory standards, including The Joint Commission (JC), and serves as the primary liaison between hospital departments, medical staff, and administration on all quality-related matters. The CQO oversees the development, implementation, and monitoring of performance improvement plans to drive continuous improvements in care delivery.
Essential Functions:
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Develop, coordinate, and implement the hospital’s performance improvement plan, ensuring alignment with quality and regulatory standards.
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Serve as the quality liaison between hospital departments, medical staff, performance improvement committees, and administration.
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Chair the performance improvement committee, leading quality initiatives and ensuring compliance with JC and other accreditation standards.
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Act as the primary contact for JC-related activities, including surveys, applications, and correspondence, to maintain continuous regulatory compliance.
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Provide education to hospital staff and medical teams on quality standards, performance improvement methodologies, and regulatory updates.
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Conduct in-service education programs on OSHA, CDC, and JC requirements to enhance staff knowledge of regulatory standards.
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Maintain thorough records of performance improvement activities and ensure accurate documentation for regulatory reviews.
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Update hospital staff on regulatory changes and communicate new quality initiatives effectively.
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Serve as a resource to all departments, providing guidance on quality and performance improvement challenges.
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Lead the JC Task Force to ensure ongoing compliance and accreditation readiness.
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Oversee medical staff performance improvement activities to enhance patient outcomes.
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Stay informed on industry best practices by reviewing professional journals and sharing relevant updates with staff.
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Perform other duties as assigned while adhering to all hospital policies and standards.
Qualifications:
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Education:
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Bachelor’s degree in Nursing, Healthcare Administration, or a related field (required).
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Master’s degree in Public Health, Healthcare Quality, or a related field (preferred).
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Experience:
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5-7 years of direct experience in nursing, quality management, performance improvement, or a related field (required).
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5-7 years of progressive leadership experience in nursing, quality management, or performance improvement (required).
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Working knowledge of hospital operations, JC standards, CMS requirements, and DOH regulations (required).
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5-7 years of clinical nursing experience in an acute care setting (preferred).
Knowledge, Skills, and Abilities:
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Expertise in quality improvement methodologies, regulatory compliance, and accreditation standards (including JC).
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Strong leadership and communication skills to foster collaboration across departments.
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Proficiency in data analysis, performance metrics, and the development of quality initiatives.
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In-depth understanding of healthcare regulations with a focus on patient safety and performance improvement.
Licenses & Certifications:
- RN - Registered Nurse State Licensure and/or Compact State Licensure (preferred).
What We Offer:
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Competitive Pay
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Medical, Dental, Vision & Life Insurance
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Generous Paid Time Off (PTO)
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Extended Illness Bank (EIB)
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Tuition Reimbursement
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Matching 401(k)
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Career Advancement Opportunities
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Rewards & Recognition Programs
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Additional Discounts & Perks*INDLEAD
To apply, please email laura_peterson2@chs.net (alixandra_dunn1@chs.net)
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.
