Job Description

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.

Why You’ll Love Working Here

• Comprehensive Health Coverage – Medical, dental, and vision plans to keep you and your family healthy.
• Future Security – 401(k) with employer matching to help you build long-term financial stability.
• Competitive Pay & Full Benefits – A salary and package designed to reward your expertise and dedication.
• Paid Time Off – Generous EIB and vacation time to support work-life balance
  

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.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• 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
• 5-7 years of direct experience in nursing, quality management, performance improvement, or a related field required
• 5-7 years of progressive leadership experience in nursing, quality management, performance improvement, or a related field required
• Working knowledge of general hospital operations, JC standards, CMS requirements, and DOH regulations required
• 5-7 years of clinical nursing experience at an acute care facility 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.

Licenses and Certifications

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

Why Work at MountainView Regional Medical Center?

At MountainView Regional Medical Center, we’re more than healthcare providers, we’re a team dedicated to compassionate care and community wellness. Join us for a supportive work environment, opportunities for professional growth, and the chance to make a real difference in the lives of our patients every day. Your skills, your passion, and your commitment matter here.

This position is not eligible for immigration sponsorship now or in the future. Applicants must be authorized to work in the U.S. for any employer.

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