Chief Quality & Patient Safety Officer

PURPOSE STATEMENT:

The Chief Quality & Patient Safety Officer provides executive leadership and is accountable for developing and implementing patient safety, clinical quality, and performance improvement strategies across all service lines. This role shapes the organization’s vision for high-reliability care, driving enterprise-wide initiatives that improve patient outcomes, reduce risk, and foster a culture of quality and patient safety. Operating within a matrixed environment, the SVP collaborates with executive and operational leadership to ensure the seamless integration of quality and patient safety priorities into daily clinical and operational practices. The Chief Quality & Patient Safety Officer oversees the Vice President of Quality and Patient Safety - SUD and Vice President of Quality and Patient Safety - Acute and partners closely with clinical, regulatory, compliance, and operational teams to drive sustainable improvements and ensure organizational excellence.

ESSENTIAL FUNCTIONS:

• Develop and execute a comprehensive strategy for patient safety and quality outcomes aligned with the organization’s mission, regulatory requirements, and industry best practices.
• Develop, review, update internal clinical procedures, outcomes measurement, patient satisfaction, clinical/financial tools, and resources.
• Work cross-functionally with clinical leaders, medical staff, risk management, compliance, and frontline teams to advance patient safety and quality initiatives.
• Collaborate with executive and operational leaders to embed quality improvement initiatives into daily operations, fostering a culture of safety and continuous improvement.
• Utilize data analytics to drive decision-making and transparency.
• Works across technology and data teams to oversee the development, implementation, and tracking of key performance indicators (KPIs) to measure and enhance patient safety, clinical quality, and operational effectiveness.
• Establish and refine systems for timely and effective reporting, investigation, and response to patient safety incidents, ensuring lessons learned are embedded in operations.
• Initiate and lead communications with regulatory agencies as appropriate.
• Ensure compliance with all federal, state, and accreditation standards related to patient safety and quality, including The Joint Commission, CARF, CMS, and state licensure requirements.
• Develop/maintain proficiency in regulatory requirements, including reporting and response to regulatory bodies.
• Lead the development and delivery of training programs to promote a culture of safety, high reliability, and accountability across all levels of staff.
• Build and mentor a high-performing quality and patient safety team, providing leadership, guidance, and professional development opportunities.
• Oversees the performance of a matrixed team of quality and patient safety professionals to ensure implementation and ongoing monitoring of quality and compliance activities.
• Monitor industry trends and emerging best practices in patient safety and quality, adapting and implementing evidence-based strategies across the organization.
• Oversee implementation of policies, procedures, and practices as its related activities to maintain ethical and conduct standards.
• Ensure proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Lead investigations into alleged violations of rules, regulations, policies, and Codes of Conduct by evaluating and recommending investigations as appropriate. Coordinate resolution of ethics reports with the Chief Compliance Officer.
• Performs other duties as assigned.
• Leadership Functions:
• Identifies and prioritizes issues of importance, including those priority issues as set for by leadership. Collaborates with department leaders and corporate executive leaders, as needed.
• Communicates instructions, expectations and timelines clearly and concisely.
• Manages staff scheduling to maintain productivity levels, curtailing unnecessary overtime and/or excessive staff work hours.
• Maintains accountability expectations for self and staff in all areas of job performance.
• Engages staff in quality and safety basics to ensure sustained, measurable compliance.
• Identifies staff educational needs and ensures they are addressed with education programs that are attended by staff.
• Hold staff accountable for non-compliance and safety concerns, as well as attendance, following policies, behavior, and adherence to the code of conduct.

ADDITIONAL RESPONSIBILITIES:

• Develops and implements program policies and procedures that guide the provision of services.
• Complies with organizational policies, procedures, performance improvement initiatives and maintains regulatory and industry standards.
• Maintains regular and reliable attendance.
• Meets expectations as an exempt employee to work additional hours as required to meet company needs and project deadlines.
• Accepts responsibility for professional growth and development of self and attends all mandatory facility in-services and staff development activities as scheduled.
• Maintains professionalism and confidentiality of facility employees and patients.
• Performs other duties as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Advanced degree(s) in healthcare-related fields, such as MD, PhD, MPH, MHA, MBA, PsyD, MSW, APRN, or related disciplines
• Ten or more years of experience in healthcare quality, patient safety, and/or clinical leadership, with at least five years in a senior leadership/management role.
• Experience within behavioral health, addiction treatment, or substance use disorder settings is highly preferred.
• Proven history of successfully implementing quality improvement initiatives in a multi-site and/or matrixed healthcare environment.
• Deep understanding of regulatory, accreditation standards, standard quality measures, and value-based care including The Joint Commission, CARF, CMS, NCQA, and state regulations.
• Proficiency in data analytics with experience utilizing data to drive strategic decision-making as well as to establish, track and trend performance towards quality and patient safety goals.
• Demonstrated ability to lead change management and foster a culture of continuous improvement, safety, and accountability.
• Experience with Lean Six Sigma, Model for Improvement, or other quality/performance improvement frameworks.
• Exceptional communication, facilitation, collaboration, and influencing skills with diverse stakeholders.
• Exercise sound judgment in responding to inquiries; understands when to elevate inquiries to the next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.
• Willingness and ability to travel extensively across the organization’s multi-state footprint.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Certified Professional in Healthcare Quality (CPHQ) or equivalent certification.
• Experience with Lean Six Sigma or other quality improvement frameworks.
• Familiarity with telemedicine and digital health applications in SUD care.

WORK LOCATION:

• This position is onsite and is not a remote position.

SUPERVISORY REQUIREMENTS:

• Ten or more years’ supervisory/management experience required, preferably in behavioral health.