Chief Quality Officer, Bellevue Hospital

The Chief Quality Officer (CQO) reports directly to the Chief Medical Officer (CMO) and is responsible for setting the vision, goals, and priorities for quality at Bellevue hospital.

This includes:

• Representing Quality & Safety within the CEO's Cabinet.
• Collaboratively setting the vision and strategy for Quality and Safety for the facility with leadership and frontline staff. Leading the Quality programs at the facility, including communication across multiple internal departments, coordination within the NYC H H system, and interactions with external agencies. The CQO represents Quality as needed in Cabinet Meetings, to the Medical Board, and during regulatory visits.
• Leading employee education, growth, mentorship, and development around Quality.
• Leading staff recognition programs around Quality.
• General oversight of the Department of Clinical Management, including the supervision of staff, approval of time and leave, and annual evaluations.

Leadership:

Collaboratively sets the vision and strategy for Quality with hospital CEO, CMO, and various Cabinet members

• Communicates across all levels about quality goals and priorities (i.e., from frontline staff to system leadership)
• Leads growth, mentorship, and development around quality, setting the foundation for implementing and sustaining a culture of continuous improvement
• Performs other related leadership activities as requested by the hospital CMO
• Oversee and Manage the Directors of Regulatory Affairs, QAPI, Risk Management, Quality Management, and Psychiatry Quality

Responsibilities:

• Accreditation & Regulatory Affairs:
  
  
  
  • Oversee hospital-wide efforts to achieve continuous readiness for accreditation surveys.
  • Integrate findings from tracers, mock surveys, and regulatory visits with QA and PI activities to improve or achieve compliance.
  • Oversee policy management, including regular review and revision
  • Remain current with current regulatory standards and update processes as needed to maintain compliance.
  • Provide staff education and preparation for regulatory visits and support executive sponsorship of public survey submissions - shared responsibility with Chief Quality Officer, Chief Nursing Officer and Chief Medical Officer to assist with final review of data and responses prior to submission.
  • Coordinate activities during regulatory visits and, as needed, responses after those visits.
  • Oversee process of working with departments on corrective actions and monitoring
  
  
  
  
• Equity
  
  
  
  • Act as the hospital leader in analyzing disparities in care delivery or outcomes
  • Integrate activities across disciplines and departments which have a specific focus on equity.
  • Work with departments to identify ways that data can be stratified according to equity measures, including health related social needs, age, ethnicity, gender, gender identity, language, race, sexual orientation, or any other factor that may represent an obstacle to optimal health.
  • Oversee the design of corrective actions and interventions to address identified disparities
  • Keep staff, leadership, and key stakeholders aware of efforts around equity.This includes review of equity data, identified disparities, corrective action plans, and progress on improvement efforts.
  
  
  
  
• Performance Improvement (PI):
  
  
  
  • Oversee the QAPI director in leading the PI program for the hospital and provide general oversight of PI programs in each of the departments
  • Serve as Executive Sponsor for PI Projects presented to the Board of Directors
  • Build PI capacity via mentorship, QAPI council, and by advancing candidates for programs such as Quality Academy and Clinical Quality Fellowships.
  • Oversee awareness building activities such as National Healthcare Quality Week
  • Engage and coordinate with system Quality leadership around PI
  • Act as Executive Sponsor for departmental focus on PI
  • Oversee the annual review of facility Performance Improvement Plans
  • Drive facility advancement in understanding of PI methodology
  
  
  
  

• Patient Safety
  
  
  
  • Support the Patient Safety Officer with the facility patient safety committee in driving performance on National Patient Safety Goals and setting priorities for Facility and System Patient Safety Goals.
  • Oversee efforts to monitor Patient Safety performance.
  
  
  
  
• Policy Management:
  
  
  
  • Oversee the process by which existing policies are reviewed, revised, and renewed on a timely basis.
  • Oversee the development of new policies and retirement of old policies by collaborating with involved stakeholders.
  • Advance efforts to streamline policy signatures and attestation, leveraging technology to assist
  
  
  
  
• Quality Assurance:
  
  
  
  • Oversee quality data analytics and reporting activities to support Quality Assurance, Performance Improvement, Patient Safety, Risk Management, Accreditation programs and activities.
  • Oversee the system by which departments track, trend, and analyze meaningful metrics
  • Assist with the development of corrective action plans when metrics are not at goal
  • Ensure that hospital leadership and front-line staff are aware of key trends in departmental data
  • Ensure that system leadership is aware of key trends in hospital data
  • Oversee external quality data analytics and reporting including required reporting, quality initiatives, and incentive programs.
  • Oversee the chart abstraction of measure data as well as validation of electronically derived measurement
  • Oversee activities of the Quality Council with key stakeholders
  
  
  
  
• Risk Management:
  
  
  
  • Oversee the Root Cause Analysis (RCA) process, including alignment with system standards and execution of corrective action plans.
  • Oversee responses to adverse events via supervision of the Director of Risk Management
  • Bridge RCA activities to QA and PI to drive improved performance when appropriate.
  • Oversee the incident management process, including review of reported incidents, analysis of trends in reported incidents, and continuous improvement of the incident reporting system.
  • Work collaboratively with the Director of Risk Management to carry out the above activities.
  
  
  
  

Physician Leader

NYU Langone Medical Center is anequalopportunityand affirmative action employer committed to diversity and inclusion in all aspects of recruiting andemployment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sexual orientation, national origin, age, religion, creed, disability, military and veteran status, genetic information or any other factor which cannot lawfully be used as a basis for anemploymentdecision. We require applications to be completed online.