Chief Quality Officer (CQO) - Healthcare Administration

Job Description

The Chief Quality Officer (CQO) leads hospital-wide quality and performance improvement initiatives to enhance patient care and ensure compliance with regulatory standards, including those from The Joint Commission (JC). The CQO serves as a key liaison between hospital leadership, medical staff, and departments, guiding strategic quality initiatives and maintaining continuous readiness for accreditation and regulatory surveys.

Essential Functions

• Directs the development, coordination, and execution of the hospital’s Performance Improvement Plan, ensuring alignment with JC, CMS, and DOH requirements.
• Serves as the primary liaison for quality improvement among departments, medical staff, and administration.
• Chairs the Performance Improvement Committee and leads all JC-related activities, including survey readiness, applications, and regulatory correspondence.
• Provides training and education on performance improvement, patient safety, and regulatory standards (JC, OSHA, CDC).
• Leads the Joint Commission Task Force to ensure consistent compliance and survey preparedness.
• Supports medical staff with performance improvement strategies to enhance clinical outcomes.
• Develops and maintains documentation for all quality activities, ensuring readiness for internal and external reviews.
• Communicates changes in quality regulations and implements new initiatives across the organization.
• Serves as a resource and consultant for departments on quality-related concerns and best practices.
• Reviews and disseminates current research and industry standards to support continuous quality advancement.
• Performs additional duties as assigned and complies with all organizational policies and standards.

Qualifications

Required:

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field
• 5–7 years of experience in nursing, quality management, or performance improvement
• 5–7 years of progressive leadership experience in a healthcare setting
• Knowledge of hospital operations, JC standards, CMS requirements, and DOH regulations

Preferred:

• Master’s degree in Public Health, Healthcare Quality, or a related field
• Clinical nursing experience in an acute care setting
• Active RN license (state or compact)

Knowledge, Skills & Abilities

• Strong understanding of quality improvement strategies and accreditation requirements
• Excellent leadership, communication, and cross-functional collaboration skills
• Proficiency in data analysis, performance metrics, and regulatory compliance
• Commitment to patient safety, clinical excellence, and operational efficiency

What We Offer

• Competitive Pay
• Medical, Dental, Vision, & Life Insurance
• Generous Paid Time Off (PTO)
• Extended Illness Bank (EIB)
• Matching 401(k)
• Opportunities for Career Advancement
• Rewards and Recognition Programs
• Additional Discounts and Perks*
• *Benefits may vary by role and location.

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