Chief Quality Officer (CQO)

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.
• Covers 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.

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.