Chief Quality Officer

Duties & Responsibilities

Under the oversight of the Chief Executive Officer (CEO) or Chief Medical Officer (CMO), leads and executes quality and safety initiatives, ensuring alignment with organizational goals and regulatory standards. Partners with leadership to set and implement strategies, drive quality assurance and ensures compliance with all regulations.

• Strategically leads vision, oversight and implementation of quality, patient safety, performance improvement, risk, and regulatory/accreditation activities.
• Represents these areas as a member of the healthcare setting CEO’s Executive Leadership.
• Leads and develops a culture of continuous improvement throughout the organization; and implements efforts to evaluate and identify inequitable access and health care disparities.
• Oversees preparation of quality assurance reports to the Quality Board and Governing Body.
• Develops, maintains, and implements effective quality and safety plans and programs focused on improving quality, patient safety, and population health outcomes.
• Leads Performance Improvement activities including quality improvement capacity building programs to engage in performance improvement methodologies.
• Represents executive leadership on Board of Directors Committees, activities and plans; co‑chairs the Facility-Based Collaborative Council; and provides executive sponsorship for public survey submissions in collaboration with the Chief Medical Officer.
• Aligns dashboard metrics with System Strategic Pillars and supports departments in identifying and improving department level and balanced scorecard initiatives.
• Provides executive leadership to Root Cause Analyses activities, execution of Corrective Action Plans (CAPs) and monitoring for compliance.
• Incorporates information learned from good catches and adverse event reporting and Root Cause Analyses into Performance Improvement activities.
• Works collaboratively with Risk Manager on risk reduction strategies, monitoring and compliance accreditation.
• Ensures continuous accreditation readiness through oversight of tracers and mock surveys.
• Creates, implements and monitors Plans of Correction, and implements information learned into Performance Improvement programs.
• Acts as the primary liaison to build capacity for staff to understand how to engage in performance improvement.
• Provides guidance and consultation on maintenance of policy and procedure system while ensuring policies are current with national standards of practice and in compliance with internal and external regulations.
• Oversees quality data analytics and reporting activities to support Quality Assurance, Performance Improvement, Patient Safety, Risk Management, and Accreditation functions utilizing standard tools for quality reporting.
• Leads chart abstraction and quality data submission to various accreditation bodies including New York State Department of Health, New York City Department of Health and Mental Hygiene, Centers for Medicare and Medicaid Services, and The Joint Commission.
• Ensures that incidents involving patient care and safety are investigated, and makes reports to the appropriate public health and regulatory agencies.
• Presences findings to related parties and incorporates new findings into affected procedural tools or programs.
• Maintains an active clinical practice in their medical specialty while balancing patient care with leadership responsibilities.
• Uses clinical expertise to drive quality improvement initiatives while ensuring patient care standards are consistently met.
• Performs other related duties.

Minimum Qualifications

Valid clinical license and current registration (MD, DO, NP) issued by the New York State Education Department (NYSED); and Medical Degree or Master’s Degree from an accredited college or university in Quality Management, Hospital Administration, Health Care Administration, or a related health care specialization; and seven (7) years of related experience partnering with executives and departmental leadership in the development of organizational strategies and implementation of regulatory survey preparation and compliance, and in performance improvement and/or continuous quality improvement initiatives in a health care setting, with three (3) years in a responsible managerial capacity. OR Valid clinical license and current registration (MD, DO, NP) issued by NYSED; and Bachelor’s Degree from an accredited college or university in relevant disciplines; and nine (9) years of related experience in the areas described, with three (3) years in a responsible managerial capacity. Certified Professional in Healthcare Quality (CPHQ) may be substituted for one (1) year of experience.