Chief Quality Officer

Chief Quality Officer

• Granger, IN
• BH EMP Admin
• Beacon Health System
• Full-time - Day - Monday - Friday 8:00 - 5:00
• Req #: 226459

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Summary

The Chief Quality Officer (CQO) provides executive leadership for the design, implementation, and continuous improvement of clinical quality, patient safety, and performance excellence across Beacon Health System. This role is accountable for driving superior outcomes across the full continuum of care, including inpatient, outpatient, ambulatory, and post-acute settings.

The CQO partners closely with physician leadership, nursing leadership, and operational executives in a matrixed environment to ensure system-wide alignment on quality strategy, standardization, and measurable outcomes. This leader serves as the enterprise authority on quality improvement, patient safety, regulatory readiness, and high-reliability care delivery.

Reporting Structure:

• Reports to: Chief Clinical Officer

Key Partnerships:

• Chief Medical Officer / Physician Leaders
• Chief Nursing Officer
• Hospital Presidents
• Ambulatory / Medical Group Leadership
• Finance, IT, and Analytics Leaders

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Key Accountabilities

Enterprise Quality Strategy & Governance:

• Develop and execute a system-wide quality and patient safety strategy aligned with Beacon's clinical excellence and value-based care goals.
• Lead the Quality Assessment and Performance Improvement (QAPI) program across all sites, ensuring regulatory and accreditation compliance.
• Establish governance structures, dashboards, and accountability mechanisms for quality performance.

Clinical Quality & Outcomes Performance:

• Drive measurable improvement in:

• Mortality, complications, and harm events

• Hospital-acquired conditions (HAIs)

• Readmissions, LOS, and throughput

• Ambulatory quality measures and preventive care performance

• Standardize evidence-based clinical pathways and reduce unwarranted variation across sites.

• Align inpatient and outpatient quality metrics into a unified system scorecard.

Patient Safety & High Reliability:

• Lead enterprise patient safety strategy, including harm reduction, culture of safety, and event reporting systems.
• Establish high-reliability organization (HRO) principles and operational behaviors.
• Oversee root cause analyses, serious safety event review, and system-wide corrective actions.

Performance Improvement & Operational Excellence:

• Oversee enterprise performance improvement using Lean/Six Sigma methodologies to reduce variation and improve outcomes.
• Build sustainable systems for continuous improvement, accountability, and standardization across inpatient and outpatient settings.
• Partner with operational leaders to translate strategy into daily workflows.

Ambulatory & Population Health Quality:

• Lead quality improvement across Beacon Medical Group and ambulatory services.
• Improve performance in value-based contracts, including preventive care, risk adjustment, and population health metrics.
• Ensure alignment of ambulatory and hospital-based quality initiatives.

Data, Analytics & Transparency:

• Partner with IT and analytics teams to develop enterprise quality dashboards and actionable insights.
• Promote data-driven decision-making and transparency across all levels of the organization.
• Ensure timely and accurate reporting to internal leadership, Board, and external agencies.

Regulatory, Accreditation & Risk:

• Oversee readiness for Joint Commission, CMS, and other regulatory bodies.
• Ensure compliance with all applicable quality and safety standards.
• Partner with Risk Management and Compliance to mitigate organizational risk.

Physician & Clinical Leadership Engagement:

• Partner in a dyad model with physician leaders to drive quality improvements.
• Build physician engagement in quality, safety, and utilization management.
• Develop and mentor clinical leaders in quality improvement methodologies.

Culture, Leadership & Change Management:

• Foster a culture aligned with Beacon's mission, values, and service standards.
• Serve as a visible champion of clinical excellence, accountability, and continuous improvement.
• Lead change management across a complex, multi-site health system environment

Key Success Metrics

• System-wide quality composite performance (inpatient + ambulatory).
• Patient safety event rates and harm reduction metrics.
• Length of stay (LOS) and readmissions.
• HCAHPS / patient experience scores.
• Value-based contract quality performance and star ratings.
• Regulatory and accreditation outcomes.
• Physician engagement in quality initiatives.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Qualifications

Education & Licensure

• Physician (MD/DO) or Registered Nurse (RN) required.
• Advanced degree required (e.g., MPH, MBA, MHA or equivalent).
• Board certification (physician) or advanced certification (nursing) preferred.

Experience

• 10+ years of progressive leadership in healthcare quality, patient safety, or clinical operations.
• Demonstrated experience leading system-wide quality improvement across inpatient and outpatient settings.
• Experience with value-based care, population health, and regulatory environments.
• Proven success working in matrixed or dyad leadership models.

Leadership Capabilities

• Data-driven decision-maker with focus on measurable outcomes.
• Strong strategic planning and execution skills.
• Ability to lead large-scale transformation across multiple sites.
• Expertise in performance improvement methodologies (Lean, Six Sigma, or equivalent).
• Exceptional collaboration and influence skills across physician and administrative teams.

What Success Looks Like

• Beacon operates as "One System" for quality, with standardized care and minimal variation.
• Quality outcomes are top quartile across inpatient and ambulatory metrics.
• Patient safety events are consistently reduced with highly reliable processes.
• Physicians and operations act as a unified, accountable team.
• Data is transparent, actionable, and drives real-time improvement.

Working Conditions

• Works in an office and patient-care environment, with occasional changes in job demands.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.

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