Chief Quality Officer

Basic Function and Responsibilities

The MSHS CQO is responsible and accountable for leading the strategy, design, and execution of Clinical Quality, Infection Prevention, Patient Safety, Risk Management, Regulatory Affairs and Clinical Performance Improvement functions across the health system. The CQO will possess proven experience with design and implementation of advanced data science and analytics, the principles of improvement science and the strategic application of fully integrated data tools and insights to evaluate current state performance and identify improvement opportunities. The CQO will work collaboratively across all clinical, operational, and academic departments to ensure alignment with system strategic goals, enforce compliance with local and federal regulations, and promote data-driven decision making and continuous performance improvement. The CQO will facilitate a culture of excellence, safety, and high-quality patient care in alignment with the MSHS mission (education, research, and clinical care), vision, and values.

As the MSHS quality and safety champion, the CQO will promote system-based improvement science, standardization of best practices in collaboration with the CCO’s office, the organization’s commitment to high reliability, and enhance the organization’s reputation as a leader in clinical outcomes.

Key Responsibilities

Quality and Safety Leadership:

• Provides strategy, leadership, and oversight for Quality, Infection Prevention, Patient Safety, Risk Management, Regulatory Affairs, and Performance Improvement relating to the Mount Sinai Health System’s quality improvement efforts
• Represents the health system in nationally and internationally prominent forums as an academic leader in the field.
• Oversees the governance structure to ensure structural alignment of quality and safety functions with the strategic directives of the health system, including patient, financial, and operational goals.
• Develops and implements a comprehensive quality improvement and patient safety strategy across the academic health system.
• Oversees clinical quality initiatives to improve patient outcomes, reduce errors, and enhance patient safety.
• Ensures compliance with all relevant regulatory agencies, accreditation bodies, and quality reporting programs (e.g., CMS, Joint Commission).

Performance Improvement:

• Develops strategy to achieve High Reliability Care and standardization goals.
• Leads multidisciplinary teams in process improvement efforts using methodologies such as Six Sigma, Lean, or Plan-Do-Study-Act (PDSA).
• Analyzes data to identify trends, areas for improvement, and opportunities for innovation in clinical care delivery. Uses advanced data science and machine learning to identify and execute upon strategies at the cutting edge of quality leadership in order to advance the field.
• Leads the design and implementation of metrics and dashboards to monitor and report on quality and safety outcomes.

Collaboration and Stakeholder Engagement:

• Cultivates and sustains a culture of continuous improvement.
• Ensures effective collaboration with Population Health and value-based care functions.
• Engages with data scientists and national/international leaders in quality to adopt best practices and to advance the field.
• Connects the need for engaged clinical staff to obtaining optimal clinical outcomes.
• Partners with clinical department chairs, faculty, and health system leadership to align quality improvement initiatives and resources with clinical care goals.
• Works with all areas of responsibility to implement evidence-based practices.
• Understands value of transparent communication to appropriate stakeholders.

Education and Professional Development:

• Leads the vision for relevant competency training, staff development in-services, and conferences to maintain and improve knowledge base, competency, and skills.
• Provides education and training to staff on regulatory requirements, patient safety, and quality improvement tools.
• Develops innovative approaches to engaging faculty and staff using advanced technology, such as AI-based training tools.
• Serves as a leader in the academic mission by mentoring and teaching faculty, staff, and trainees on quality improvement and patient safety principles.
• Participates in the development and dissemination of quality improvement research and publications inclusive of podium presentations both nationally and internationally.
• Actively participates in the performance planning, competency, and individual development planning process.

Regulatory Compliance and Accreditation:

• Ensures the health system meets and exceeds standards set by regulatory agencies and accrediting bodies, such as The Joint Commission and Centers for Medicare & Medicaid Services (CMS).
• Oversees and provides strategy to prepare the health system for accreditation and quality inspections, leading efforts to maintain compliance and implement corrective actions where necessary.

Data Analytics and Reporting:

• Leverages and designs advanced data analytic approaches to drive clinical decision-making, reduce variability in care, and enhance patient safety and outcomes. Uses data science and machine learning tools in collaboration with CDIO, CMIO and CNIO to adopt holistic approaches to data integration across the health system in applicable areas.
• Leads quality and patient safety-related technology improvements across the health system.
• Interacts with Clinical Operations Data team and CDIO to enable functions of the Chief Quality Officer to make data-driven decisions and drive initiatives forward effectively.
• Presents performance data and improvement plans to executive leadership, the Board of Directors, and other stakeholders.

Innovation and Strategic Planning:

• Collaborates in the development an innovation strategy that is endorsed by key stakeholders, including system hospital and ambulatory leadership, site leadership, and site staff.
• Leads the integration of new technologies and innovative solutions to improve quality, patient safety, and operational efficiency.
• Develops long-term strategic goals for quality and safety that align with the academic health system’s mission and vision.
• Designs and executes a business strategy that will allow for future innovation and growth.

Financial Management:

• Displays strong business acumen, sophisticated knowledge of healthcare, and experience in a competitive marketplace with the ability to make complex and difficult decisions.
• Develops, monitors, and implements operating and capital budgets of assigned areas.
• Develops, implements, and evaluates cost-effective initiatives related to operations.
• Maintains accountability for fiscal management as assigned.

Leadership Competencies

• Develops a high performing team.  Recruits, retains, and develops a high-functioning team.  Fosters a culture of respect and belonging.
• Mobilizes stakeholders outside of his/her individual span of control.
• Takes a proactive, people-centered, and deliberate approach to leadership development, talent management, and succession planning, recognizing that people are Mount Sinai Health System’s most critical asset.
• Continually fosters transparent and ongoing communication and flow of information amongst and between leadership, employees, and key stakeholders.
• Collaborates with HR, leverages a position control process to balance budgetary targets and service and performance levels.
• Strong strategic thinking, strategic execution, and problem-solving abilities, with the capacity to identify and address complex clinical challenges.
• Exceptional communication and interpersonal skills, with the ability to engage and collaborate with various stakeholders, including clinicians, administrators, and IT professionals.
• Strong knowledge about industry-leading high reliability and improvement methodologies (including Lean thinking and others) and clinical analytics.
• Strong knowledge of clinical analytics and industry trends related to improvement, culture, patient / consumer engagement and preferences, clinical practices, and patient safety.
• Familiarity with clinical informatics and data analytics, including the ability to leverage data for decision-making and performance improvement.

Key Competencies

• Strategic Thinking
• Expertise in applying Data Science and Machine Learning to drive strategy
• Dynamic leader that advances the field of health care quality science
• Analytical and Problem-Solving Skills
• Leadership and Team Building
• Communication and Stakeholder Management
• Innovation and Change Management
• Regulatory and Compliance Knowledge
• Demonstrated experience in program planning, implementation, and evaluation

Reports to:                       

Chief Clinical Officer, MSHS

Direct Reports:             

Hospital Chief Medical Officers

Vice President, Risk Management, MSHS

Vice President, Medical Affairs, MSHS

Vice President, Medical Staff Services, MSHS

Medical Director, Infection Prevention

Quality/Regulatory Affairs Leadership

Key Internal Relationships:                  

Chief Nurse Executive, MSHS, and Site Chief Nursing Officers

Deputy Chief Clinical Officer, MSHS

Chief Clinical Innovation Officer, MSHS

Chief Digital and Information Officer

Department Chairs & Service Line Leaders

MSHS Ambulatory Leadership

Desired Qualifications

• MD, DO, or advanced clinical degree (PhD, RN, NP, etc.) is required.
• Demonstrated proficiency in advanced data analytics, including machine learning and artificial intelligence
• Master’s degree in health administration, public health, business administration, or a related field is strongly preferred.
• Minimum of 10 years of clinical experience with a proven track record in quality and patient safety leadership roles within a complex health care setting.
• Experience in academic setting as an appointed faculty member at the full professor level with tenure or substantial equivalent.
• Experience participating in or leading grant-funded research with authorship in national and international publications.
• Expertise in quality improvement methodologies (e.g., Six Sigma, Lean, PDSA) and patient safety standards.
• Strong knowledge of clinical operations, quality improvement methodologies, high reliability, human factors engineering, and healthcare technology solutions.
• Experience working in an academic health system or integrated delivery network is strongly preferred.

About Mount Sinai Health System

Mount Sinai Health System is among New York City’s largest employers, with 42,000+ team members in both clinical and non-clinical roles throughout our eight hospital campuses and world-renowned medical school. We are one of the metro area’s largest health care providers, with hundreds of ambulatory, primary, and specialty care facilities across the five boroughs, the northeastern region, and beyond. Ready to make an impact? Explore our career specialty selections below and join a team that’s dedicated to shaping the future of healthcare.

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