Chief Quality Officer (CQO)

Job Description

Job Summary
The Chief Quality Officer (CQO) is responsible for leading and coordinating quality improvement and performance initiatives throughout the hospital. This role 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. The CQO develops, implements, and monitors performance improvement plans to ensure continuous improvement in patient care and operational excellence.
Essential Functions

• Oversee the development, coordination, and implementation of the hospital's performance improvement plan, ensuring alignment with quality and regulatory standards.
• Serve as a quality liaison between all hospital departments, medical staff, performance improvement committees, and administration to ensure a cohesive approach to quality improvement initiatives.
• Chair the performance improvement committee, leading quality improvement efforts and ensuring compliance with Joint Commission (JC) regulations and other accreditation standards.
• Act as the primary contact for all JC-related activities, including surveys, applications, and correspondence, ensuring continuous regulatory compliance.
• Provide education to hospital staff and medical teams on quality standards, performance improvement methodologies, and regulatory updates.
• Develop and conduct in-service education programs to enhance staff knowledge of quality improvement and regulatory standards, including OSHA, CDC, and JC requirements.
• Maintain complete records of all performance improvement activities and ensure accurate documentation for regulatory reviews.
• Update hospital staff on changes to regulatory standards and ensure timely communication of new quality initiatives.
• Act as a resource to all departments on quality and performance improvement matters, providing guidance and support for quality-related challenges.
• Lead the JC Task Force to ensure ongoing compliance with regulatory requirements and prepare the hospital for accreditation surveys.
• Coordinate medical staff performance improvement activities, working closely with clinical teams to enhance patient outcomes.
• Review and disseminate updated information from professional journals, ensuring staff have access to the latest developments in quality and performance improvement.
• Perform other duties as assigned.
• Comply with all policies and standards.

Qualifications
Education:

• Bachelor's Degree in Nursing, Healthcare Administration, or a related field required.
• Master's Degree in Public Health, Healthcare Quality, or a related field preferred.

Experience:

• 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.
• Proficiency in healthcare regulations and compliance, with a focus on patient safety and performance improvement.
• Ability to analyze trends, create reports, and implement best practices for hospital-wide quality improvements.
• Adept at problem-solving and implementing solutions to improve patient outcomes and hospital performance.

Licenses and Certifications

• RN - Registered Nurse (State Licensure and/or Compact State Licensure preferred).
• Certified Professional in Healthcare Quality (CPHQ) designation preferred (Arizona-specific requirement).

State-Specific Requirements

• Arizona: Certified Professional in Healthcare Quality (CPHQ) designation preferred.

This position plays a vital role in ensuring high-quality patient care and maintaining compliance with national healthcare standards. The ideal candidate will demonstrate strong leadership, regulatory knowledge, and a passion for quality improvement in a hospital setting.

INDLEAD
To apply, please email laura_peterson2@chs.net