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Chief Quality Officer

Physician Affiliate Group of New York (PAGNY)

Last Updated: 5/06/22

Job Description

Kings County Hospital Center

PREAMBLE: Kings County Hospital Center has played a leading role in providing a full range of health care services to the residents of Brooklyn for more than 175 years. We are a member of the New York City Health and Hospitals Corporation. We operate a Level I Trauma Center in a state-of-the-art teaching facility and provide a full spectrum of inpatient and outpatient services including Medicine, Surgery, Pediatrics, Behavioral Health, Women’s Health and Rehabilitation Medicine.

MISSION: Our mission is to provide quality health care services to a culturally and linguistically diverse population, regardless of their ability to pay. We recognize that every patient and every employee has great value. Therefore, our highest organizational priority must be respect for our patients, our visitors, and one another.

VISION: Our vision is to be the hospital of choice for the residents of Brooklyn and our employees. We strive to deliver the highest quality healthcare services with an emphasis on patient safety in a customer-centered environment.

OUR VALUES: Respect: We respect our patients including their right to privacy and confidentiality. We embrace our patients’ and employees’ cultural diversity and religious beliefs. • Safety: We strive to provide the safest possible care in a secure environment for all. • Teamwork: We recognize the contribution of all and foster collaboration across disciplines. • Trust: We encourage honest and open communication with patients and among staff. • Customer focus: We strive to meet and exceed the expectations of our customers. • Celebration: We celebrate our successes and thank staff for their contributions and customers for their loyalty. • Compassion: We serve our patients with compassion, empathy and professionalism.


Cabinet level position leading vision, strategy and implementation of Quality, Patient Safety, Risk, and Regulatory/Accreditation activities across the facility.


Represent Quality and Safety in the facility CEO's Cabinet

Collaboratively set the vision and strategy for Quality and Safety for the facility with leadership and frontline staff

Lead the Quality and Safety programs at the facility

Communicate across all levels and facilities within the organization (frontline staff, facility leadership , system leadership, colleagues in other facilities , )

Lead employee education, growth, mentorship, and development around Quality, Patient Safety, and Leadership

Implement and sustain a Culture of Safety

Lead staff recognition programs around Quality and Safety

Quality Assurance

Responsible for quality assurance activities for facility, system, and regulatory requirements

Oversee data collection and chart abstractions activities

Responsible for TJC Core Measures submissions

Responsible for quarterly Quality Assurance Performance Improvement (QAPI) reports and preparation for QAPI Committee Meetings of the Board

Responsible for semi-annual Governing Body Reports of the Board

Performance Improvement

Lead performance improvement activities across the facility

Lead performance improvement capacity building programs including Quality Improvement 101, Healthcare Administration Scholars Program, Quality Academy , Quality/Clinical Leadership Fellowship, trainings for middle managers and executive leaders

Serve as executive sponsor for 5 Board QAPI Committee performance improvement initiatives for each year

Align facility dashboard Quality metrics with system Strategic Pillars and system dashboard

Support facility departments/units with identifying and improving balanced scorecard initiatives for each calendar year (at last one initiative within each strategic pillar)

Serve as executive sponsor and/or co-chair for the Facility Based Collaborative Council (FBCC)

Responsible for annual Performance Improvement Plans

Ensure facility and system-wide learning around Performance Improvement

Responsible for facility-based analysis, dissemination, and improvement on biannual Patient Safety Culture Survey results

Responsible for annual Patient Safety Plans

Patient Safety

Executive sponsorship of public survey submissions - shared responsibility with Chief Medical Officer to make final review of data and responses prior to submission

Support the Patient Safety Officer and Patient Safety Associate with the facility Patient Safety committee, system and facility annual Patient Safety goals, and ensuring high performance in the National Patient Safety Goals

Responsible for facility-based analysis dissemination and improvement on biannual Patient Safety Culture Survey results

Responsible for annual Patient Safety Plans

Risk Management

Serve as an executive sponsor to Root Cause Analysis (RCA) activities and execution of Corrective Action Plans (CAPs)

Incorporate information learned from near-miss and adverse event reporting and RCA's into Performance Improvement activities

Work collaboratively with Risk Manager on risk reduction strategies

Regulatory and Accreditation

Serve as an executive sponsor to continuous readiness efforts for regulatory body surveys including tracers, mock surveys, and creation and implementation of Plans of Correction

Incorporate information learned from tracer and survey activities into Performance Improvement efforts

Maintain policy and procedure system

Ensuring policies and procedures are up to date and in compliance with internal and external regulations

Provide education to fac ility staff on regulatory requirements to ensure continuous readiness for the next patient and surve

Quality Data Analytics and Reporting

Oversee quality data analytics and reporting activities to support Quality Assurance, Performance Improvement, Patient Safety , Risk Management, and Regulatory & Accreditation efforts

Utilize standard system-wide tools for Quality reporting (A3, run charts, control charts, Pareto charts, driver diagrams, spider diagrams, Pl project charter, etc.)

Responsible for chart abstraction and Quality data submission to regulatory bodies including NYS DOH, NYC DOH, CMS, TJC

Utilize dashboards to track facility-wide Quality & Safety effort

Other Duties

Perform other duties as indicated by facility and system leadership

  • Minimum of Bachelor's level degree with strong preference for Master's level degree or MD preferred
  • Strong leadership and change management skills
  • Superior organizational, planning, and project management skills
  • Desire and ability to work with multiple stakeholders including business, clinical, and IT leadership and staff
  • Excellent customer service and people skills
  • Willing to travel to NYC Health + Hospitals facilities within the 5 boroughs

Proof of Covid Vaccination is required prior to hire


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Company Details

New York, New York, United States
PAGNY (Physician Affiliate Group of New York) is one of the largest multi-specialty disciplinary groups in the country.  Our main purpose is to nurture and embolden the healthcare providers who take care of the most fragile and vulnerable patients in New York City.  Affiliated with NYC Health & Hospitals, PAGNY people do more than diagnose and treat; we uplift the spirits a...