**Job Summary** The Chief Quality Officer (CQO) is responsible for leading and coordinating quality improvement and performance initiatives throughout the hospital. The CQO ensures compliance with regulatory standards, including The Joint Commission (JC), and serves as a liaison between hospital departments, medical staff, and administration on all quality-related matters. This role oversees the development, implementation, and monitoring of performance improvement plans, ensuring continuous improvement in patient care and operational excellence. **Essential Functions** + Oversees the development, coordination, and implementation of the hospital’s performance improvement plan, ensuring alignment with quality and regulatory standards. + Acts as a quality liaison between all hospital departments, medical staff, performance improvement committees, and administration to ensure a cohesive approach to quality improvement initiatives. + Chairs the performance improvement committee, leading quality improvement efforts and ensuring compliance with Joint Commission (JC) regulations and other accreditation standards. + Serves as the primary contact for all JC-related activities, including surveys, applications, and correspondence, ensuring continuous regulatory compliance. + Provides education to hospital staff and medical teams on quality standards, performance improvement methodologies, and regulatory updates. + Develops and conducts in-service education programs to enhance staff knowledge of quality improvement and regulatory standards, including OSHA, CDC, and JC requirements. + Maintains complete records of all performance improvement activities and ensures accurate documentation for regulatory reviews. + Updates hospital staff on changes to regulatory standards and ensures timely communication of new quality initiatives. + Acts as a resource to all departments on quality and performance improvement matters, providing guidance and support for quality-related challenges. + Leads the JC Task Force to ensure ongoing compliance with regulatory requirements and prepares the hospital for accreditation surveys. + Coordinates medical staff performance improvement activities, working closely with clinical teams to enhance patient outcomes. + Reviews and disseminates updated information from professional journals, ensuring staff have access to the latest developments in quality and performance improvement. + Promotes a culture of continuous improvement and patient safety throughout the hospital. + Performs other duties as assigned. + Complies with all policies and standards. **Qualifications** + Bachelor's Degree in Nursing, Healthcare Administration, or a related field **required** + Master's Degree in Public Health, Healthcare Quality, or related field _preferred_ + 7-9 years of experience in quality management, performance improvement, or a related field, with at least five (5) years in a leadership role **required** + RN - Registered Nurse - State Licensure and/or Compact State Licensure _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. + Proficient in healthcare regulations and compliance, with a focus on patient safety and performance improvement. **What we offer:** Competitive Pay - Medical, Dental, Vision, & Life Insurance - Generous Paid Time Off (PTO) - Extended Illness Bank (EIB) - Tuition Reimbursement - Matching 401(k) - Opportunities for Career Advancement - Rewards and Recognition Programs - Additional Discounts and Perks* INDLEAD To apply, please email laura_peterson2@chs.net (alixandra_dunn1@chs.net) Equal Employment Opportunity This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.