Chief Quality Officer - Healthcare Administration

Job Description

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:

• 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

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred