Chief Quality Officer - Healthcare Administration

The Chief Quality Officer (CQO) is responsible for driving quality and performance improvement initiatives across the hospital. This role ensures compliance with regulatory and accreditation standards-including The Joint Commission (JC)-while fostering a culture of safety, accountability, and continuous improvement. Acting as a key liaison among departments, medical staff, and leadership, the CQO champions operational excellence and optimal patient outcomes.

What We Offer:

• Competitive Pay
• Medical, Dental, Vision, and Life Insurance
• Generous Paid Time Off (PTO)
• Extended Illness Bank (EIB)
• Matching 401(k)
• Opportunities for Career Advancement
• Rewards & Recognition Programs
• Exclusive Discounts and Perks*

Essential Functions

• Lead the development and execution of the hospital's Performance Improvement Plan to align with quality benchmarks and regulatory requirements.
• Serve as the primary liaison for quality-related efforts across departments, medical staff, performance improvement committees, and administration.
• Chair the Performance Improvement Committee, ensuring active progress on quality initiatives and full compliance with Joint Commission and other regulatory standards.
• Manage all Joint Commission activities-including survey preparation, applications, and communication-to ensure readiness and ongoing compliance.
• Educate staff and clinical teams on quality metrics, performance improvement methodologies, and evolving regulatory standards.
• Develop and lead in-service education sessions covering JC, OSHA, CDC, and other regulatory topics.
• Maintain comprehensive documentation of all quality initiatives and performance improvement activities for audit readiness.
• Regularly update hospital staff on regulatory changes and lead implementation of new quality programs.
• Act as a subject matter expert and internal consultant on quality-related challenges across all departments.
• Lead the JC Task Force and coordinate all accreditation readiness activities.
• Support medical staff in clinical performance improvement efforts focused on optimizing patient outcomes.
• Disseminate relevant updates and best practices from professional publications and industry sources.
• Perform other related duties as assigned and maintain compliance with all organizational policies.

Qualifications:

Required :

• RN - Registered Nurse - State Licensure and/or Compact State Licensure
• Bachelor's Degree in Nursing, Healthcare Administration, or related field
• 5-7 years of direct experience in nursing, quality management, performance improvement, or related field
• 5-7 years of progressive leadership experience in similar settings
• Strong knowledge of hospital operations, Joint Commission (JC) standards, CMS requirements, and Department of Health (DOH) regulations

Preferred :

• Master's Degree in Public Health, Healthcare Quality, or related field
• 5-7 years of clinical nursing experience in an acute care setting

Knowledge, Skills and Abilities

• Deep understanding of quality improvement strategies, regulatory compliance, and accreditation standards (JC, CMS, DOH)
• Exceptional leadership, communication, and collaboration skills across multidisciplinary teams
• Strong analytical abilities with experience in quality metrics, data interpretation, and performance improvement planning
• Skilled in fostering a culture of safety and accountability

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