Position Summary

The Chief Quality Officer (CQO), is an executive physician leader who develops, implements, directs, and evaluates system-wide quality, safety, performance improvement, patient experience, and infection control programs in support of the goals of the Health System. The incumbent is responsible for leading the development, implementation, evaluation, and refinement of the overarching quality, patient safety, and patient experience strategy. The CQO is responsible for operational oversight of the following functions: quality and patient safety, accreditation and regulatory readiness, process and performance improvement, healthcare quality data analytics and insights, patient experience, and other system-based functions as assigned.

Reporting directly to the Chief Operating Officer, this role integrates three critical enterprise capabilities-quality, patient safety, and performance improvement-into a single, disciplined organizational structure. The CQO ensures that quality and safety are not only well-defined but translated into executable priorities with clear ownership, sequencing, performance measurement, and accountability across the System.

This physician executive partners closely with clinical, operational, financial, and governance leaders to develop strategies and lead; facilitates and supports cross-functional teams to improve and redesign operational and administrative processes critical to safe, high-quality, efficient, and patient- and family-centered care. The CQO will guide clinical and operational quality by partnering with medical staff leaders and physicians. Working directly with the hospital directors and managers of Quality, Patient Safety and Performance Improvement.

Education

• Board-certified physician, MD, or DO - Required

Experience

• At least 5 years of leadership experience with responsibility for oversight of core quality functions such as patient safety, clinical performance, quality and performance measurement and reporting systems, accreditation and regulatory readiness, and executive-level performance presentation and reporting - Required
• At least 5 years of executive leadership experience, preferably in a complex health system, in an executive quality (e.g., CQO or VP, quality and safety) position - Required
• Extensive knowledge of healthcare issues, trends, in complex healthcare delivery settings - Required
• Working knowledge of Lean Six Sigma improvement methodology - Required
• Strong operational and financial acumen with the ability to develop, lead, and partner based on a vision for excellence that includes continuous improvement in quality, safety, and cost-of-care reductions - Required

License & Certification

• Certified Professional in Healthcare Quality - Preferred

Values

1. Compassion - Awareness and concern for others; shows kindness, understanding, respect, empathy, is considerate of others and treats them with tolerance.
2. Quality - Superior of kind, degree of excellence. Does the right thing at the right time and in the best way.
3. Integrity - Steadfast adherence to an ethical or moral code. Does what is right and is honest.
4. Courtesy - Willingness and generosity in providing a service. Demonstrates polite, caring, cooperative and respectful behavior.
5. Accountability - Willingness to accept responsibility, open to feedback, accountable for the prudent use of our resources.
6. Team Work - Cooperative effort to achieve common goals; carries their own part of the workload and understands how it affects others, offers to assist if needed.

Expectations

1. Patient/Customer Satisfaction - Demonstrates Smart Service and a commitment to a Culture of Always to provide excellent service and the best patient experience possible.
2. Confidentiality - Maintains a secure and trusting environment, treats customer/patient information as confidential. Uses appropriate judgement with Protected Health Information, co-worker information and SJ/C proprietary information.
3. Concern for Safety - Promotes a safe work environment; strives to eliminate potential workplace hazards and reports both safety events and near misses.
4. Policy Compliance - Complies timely with assigned policy requirements for regulatory compliance (i.e. acknowledgement of assigned policies).
5. Education Compliance - Complies timely with assigned learning requirements for regulatory compliance (i.e. acknowledgement of assigned computer based learning).
6. Annual Physical Assessment - In accordance with regulatory requirements, complies timely with fit for duty assessment through Occupational Health.
7. Attendance - Limits unplanned absences, arriving tardy and leaving early without prior approval.

Core Job Functions

1. Works directly with the Chief Operating Officer and other executives and senior leaders to develop, direct, coordinate, and evaluate a comprehensive and aligned quality management and patient safety program for the health system.
2. Leads the development, implementation, and advancement of strategy to fully integrate the tools of Lean and Six Sigma into core process improvements. Is directly responsible for the data-driven environment of quality and cost improvement and develops systems to review and analyze the utilization of resources with objective measurement of care in both inpatient and outpatient settings.
3. Establishes systems and structures to optimize quality, patient safety, patient experience, and clinical outcomes performance.
4. Works with quality leaders on efforts to design and implement process simplification, waste elimination, and service improvement projects using Lean, Six Sigma, and other approaches and tools. Leads efforts to identify resolutions to issues that arise during projects or initiatives.
5. Leads, facilitates, consults with, and engages organizational leaders, physicians, and staff in the design and definition of desired future-state objectives that will meet or exceed overall strategic objectives and operational needs as outlined and supported within key quality core functions.
6. Ensures regulatory compliance with DNV, TJC, CMS, DOH, and other licensing or accrediting bodies.

Requirements

Computer Applications - Systems

• Outlook
• Intranet
• Microsoft Office
• Meditech
• Symplr Performance
• Symplr Learning

Equipment

• Computer
• Scanner
• Copier

Required Physical Demands

• Sitting - 5 - 6 hrs
• Standing/Walking - 1 - 2 hrs
• Bending - 0 - 1 hrs
• Kneeling/Crawling/Crouching - 0 - 1 hrs
• Climbing - 0 - 1 hrs
• Reaching - 0 - 1 hrs
• Pushing or Pulling - 0 - 1 hrs
• Repetitive use of Hand - Both Hands
• Grasping - Both Hands
• Fine Dexterity - Both Hands
• Color Vision - ability to distinguish color - Yes
• Lift and Carry - 10 lbs or less - Seldom

Exposures

• Blood or Body Fluids - Never
• Radiation - Never
• Hazardous Drugs - None
• Hazardous Chemicals - None

Personal Protective Equipment

• Safety Shoes - None
• Hearing Protection - No
• N-95 Respirator - No
• Lead Apron - No
• Safety Glasses - None
• Gloves - None