DescriptionJob SummaryThe 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 qualityrelated 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 hospitals 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 JCrelated 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 inservice 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 qualityrelated 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.
QualificationsEducation:
- Bachelors Degree in Nursing Healthcare Administration or a related field required.
- Masters Degree in Public Health Healthcare Quality or a related field preferred.
Experience:
- 57 years of direct experience in nursing quality management performance improvement or a related field required.
- 57 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.
- 57 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 hospitalwide quality improvements.
- Adept at problemsolving 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 (Arizonaspecific requirement).
StateSpecific Requirements- Arizona: Certified Professional in Healthcare Quality (CPHQ) designation preferred.
This position plays a vital role in ensuring highquality 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.
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