Title: Chief Quality Officer (CQO)

Reporting Relationship: Chief Executive Officer (CEO)

General Summary of Responsibilities:

• Provides clinical and administrative leadership and direction to the quality division and other assigned departments.
• Facilitates development, implementation, delivery and evaluation of services within the assigned areas through collaboration with the clinical/medical staff, nursing leaders, and other managers. Assures achievement of goals and adherence to policies, procedures, and standards set forth by state, federal, and hospital regulatory agencies. Creates an environment of innovation and creativity.
• Accountable for establishing operational mechanisms and quality leadership structures which facilitate safe and quality patient care and working environment.

Essential Job Functions:

Communication and Relationship Management

• Builds collaborative relationships
• Communicates organizational vision, mission and values
• Demonstrates effective written, oral communication and presentation skills
• Builds effective physician/provider and administrative leadership teams

Leadership

• Creates an organizational climate that encourages teamwork
• Encourages a high level of commitment to the purpose and values of the organization
• Participates in the creation of a performance-based culture that maximizes employee potential and fosters high ethical standard in meeting BBGH’s vision, mission and values
• Establishes compelling organizational goals
• Explores opportunities for the growth and development of the organization on a continual basis
• Plans for leadership succession

Professionalism

• Acquires and stays current with the professional body of knowledge
• Mentors, advises, coaches and develops all assigned managers.
• Networks with colleagues

Change Leadership

• Develops and implements a division vision that integrates hospital and program goals, priorities and values
• Balances change and continuity
• Strives to improve patient and customer service and program performance
• Creates a work environment that encourages creative thinking
• Maintains role, focus, intensity and persistence, even under adversity

Knowledge of the Healthcare Environment

• Demonstrates knowledge of corporate compliance laws and regulations (e.g. HIPAA, billing and coding practices, antitrust, conflict of interest, etc.)
• Demonstrates an understanding of global healthcare issues, trends and perspectives (e.g. population health, insurance costs, malpractice crisis, healthcare workforce shortages, etc.)
• Demonstrates an understanding of regulatory and administrative environment in which the organization functions (e.g. Stark laws, accreditation, etc.)

Business Knowledge and Skills

• Demonstrates an understanding of Systems Thinking
• Demonstrates an understanding of Project management oversight
• Evaluates whether a proposed solution aligns with the organizational business plan
• Uses sound Performance Improvement, Lean Thinking and Six Sigma tools to successfully guide projects to timely completion.
• Acquires and administers human, financial, material and information resources in a manner that instills trust and accomplishes BBGH’s mission and vision.

Professional Expectations

• Functions as the hospital’s Corporate Compliance Officer and Risk Manager.
• Maintains responsibility and oversight for the areas of Quality Management, Safety, Corporate Compliance, Risk Management, Utilization Management, Social Service, Infection Control, Accreditation, Behavioral Health, and Employee Health programs.
• Serves as the chief spokesperson for patient grievance and patient satisfaction processes.
• Coordinates hospital Ethics Committee activities, hospital safety program, and employee safety program.
• Arranges for and provides education to medical and hospital staff regarding policies, standards, regulations, laws, current protocols, and best practice guidelines.
• Collaborates with other executives in the organization in making decisions about health care services, settings, and organizational priorities.
• Directs budget preparation, resolves problems that may arise and presents balanced budget to the CEO.
• Fosters an environment of accountability and relentlessly pursues continuous improvement within the hospital.
• Responsible for the development of leadership within the division.
• Attends on-site and off-site seminars and professional association meetings. Keeps current with the literature appropriate to hospital operations.
• Serves as an advocate for continuing education, staff development, and organizational development.

This position description is intended to describe the major elements and requirements of the position and should not be taken as an exhaustive list of all responsibilities, duties, and skills required of individuals assigned to this position.

Job Qualifications:

Education

Required: Bachelors or higher degree in social work, nursing, health or human services field, population health, from an accredited college or university, or equivalent.

Preferred: Master’s degree in social work, nursing, health or human services field, population health, from an accredited college or university, or equivalent.

Conditional: Master’s degree in social work, nursing, health or human services field, population health, from an accredited college or university, or equivalent within four years of employment start date.

Experience:

Required: Five years’ leadership experience in acute, hospital, or managed health care setting, including experience in quality, infection control, epidemiology, or related field

Preferred: Recent experience in quality management, corporate compliance, utilization management, discharge planning, or social work and familiarity with The Joint Commission accreditation process

License/Certifications

 Required: Membership in the American College of Healthcare Executives (ACHE

Current Basic Life Support (BLS) for healthcare workers

Valid Driver's License 

Preferred: Certification in infection control, and related areas of responsibility

 Conditional: APIC membership within two years of employment

Personal Skills:

• A team player with outstanding interpersonal and relationship management skills with a track record of developing and maintaining good relationships with staff at all levels, and the ability to deal with challenging situations, conflict and ambiguity in a productive manner, demonstrated by a fair and consistent approach; willingness to confront and raise issues before they become problems.
• A self-motivated individual with a superior intellect who is clear on the organization’s vision, developing the necessary strategic skills to help lead an organization in the future.
• Excellent communication skills, both oral and written; good listening skills; the ability to translate complex issues into comprehensible ideas and concepts. Able to express ideas in a succinct, compelling and persuasive manner.
• An innovative individual who will bring fresh approaches and new ideas to an organization with a strong culture whose CEO believes innovation is necessary for future organizational growth, and for improving quality, service, and financial performance.

• Strong executive presence and energy; confident and self-motivated, deriving personal satisfaction from contributing to an organization’s success; an ability to establish positive working and interpersonal relationships with people at all levels.
• An ability to take projects from conception to implementation successfully and to contribute at all levels.
• An analytical nature and the ability to plan and think a problem through to identify potential consequences and solutions.

• The ability to make difficult decisions and to say “no” when it is not popular to do so.
• A hands-on leader with a willingness to “roll up the sleeves” when necessary.
• A management style which is inclusive, but demands accountability; a self-motivated, highly intelligent, secure individual, who is team oriented and has a passion for service excellence.
• A high level of honesty, integrity and personal ethics; a straightforward and open style with the ability to build and facilitate effective teams; visible and accessible to medical staff and employees.
• A team builder and collaborator who is oriented to build consensus but is also comfortable making difficult decisions.
• An ability to coordinate multiple activities and projects simultaneously.

• Expert in developing and implementing strategies to address opportunities for improving the quality of care delivered to patients

• Manages conflict effectively and cooperatively

Ability to initiate and implement actions and projects which serve the mission, vision and values of Box Butte General Hospital

Box Butte General Hospital is a Equal Opportunity Employer

Post-offer/pre-employment background check and drug-screen are required,