University of Rochester Chief Nursing Officer in Rochester, New York


Full Time 40 hours


Job Summary:

The Chief Nursing Officer is a member of senior leadership and participates in executive-level decision-making. Responsible for planning, organizing and directing the overall operations of Nursing/Patient Care Services (i.e., Med/Surg Floor, OR, Employee Health/Infection Control, /Education/QI, Social Services/Discharge Planning, Utilization Review). Ensures compliance with patient care quality standards as it relates to the care provided to all age groups of patients ranging from neonate to geriatric. Maintains performance improvement activities within the department and participates in CQI activities. Assures competency of all nursing personnel (SANE). Assists in formulating the budget and maintains efficient and effective departmental operations while required compliance with all state, federal, and local regulations laws, standards, and protocols. Direct the training and instruction of nursing students.

Nursing Department Structure and Skills Meet Hospital Current & Future Needs

  • Analyzes the skills and capabilities of the functional area; identifies future workforce requirements; and identifies a means to close any gaps. Ensures processes are in place for unleashing the full potential of others by providing needed resources, coaching, experiences and other support to place the right people in key roles and continuously upgrade their skills and knowledge.
  • Diagnoses whether assigned functional areas are performing at full potential and ensures communication cascades down through the organization.Breaks down organizational silos, bridges communication gaps, and engages the employees they manage so each person understands how they can contribute to the organization’s success.
  • Acts as a champion for change. Develops, plans, and follows through on change initiatives. Helps others to successfully manage organizational change. Facilitates the implementation and acceptance of change within the workplace. Accepts the ambiguity that comes with change activities.
  • Develops the management skills of the nursing management team so that the following is completed in a timely and consistent fashion: interviewing, hiring, and orienting new employees; assign, schedule and supervise nursing staff; complete performance appraisals and initiate promotions, transfers, disciplinary action, and termination of employment; investigate or review deviation from standards or policies and take corrective action; promote and provide all clinical professional growth and education through in-service or continuing education.
  • Participates in the development of the annual Hospital strategic plan and Hospital guidelines.Develops annual goals for nursing services that are consistent with the overall Hospital strategic plan.

Programs, Policies, and Procedures that Measure, Assess and Improve the Quality of Nursing Care Delivered to Patients

  • Works closely with the Chief Medical Officer (CMO) and other administrative personnel to provide leadership for nursing and clinical services, addressing quality improvement initiatives and monitoring for desired outcomes.
  • Maintains continuing quality assessment and improvement analysis and evaluation of patient care delivery and communicates with Administration on the activities/issues of Nursing/Patient Care Services.
  • Develops and oversees implementation of appropriate patient care initiatives within nursing and clinical services that enhance their contribution to the Mission and Vision of SJMH.
  • Interacts with quality and risk management personnel, integrating nursing quality improvement efforts into the overall hospital performance improvement initiatives.
  • Establishes clear, concise and written policies and procedures consistent with standards of patient care, quality assurance activities, staffing requirements, productivity standards, rules, regulations and strategies for care delivery.
  • Reviews and monitors, through quality improvement processes, patient and employee incident reports, actions taken and the resulting outcomes.Ensures that all deviations from standards have appropriate dispositions.
  • Ensures assigned areas are in compliance with TJC standards and federal/state regulations.
  • Ensures collaboration among all disciplines concerned with patient services to provide appropriate, effective and coordinated services to patients.
  • Ensures compliance with New York Patient Occurrence Reporting and Tracking System (NYPORTS) by ensuring timely entry into the database, reporting to DOH as required, completion of a root cause analysis, and remediation planning.
  • RCA’s

New York State Quality Programs Goals and Funding Needs Met

  • Leads the Hospital participation in community-level collaborations to achieve program goals for the following:

Patient Complaints Investigated & Resolved within Regulatory Guidelines

  • Oversees the Hospital inpatient and outpatient quality reporting programs data collection and complaints and grievances.
  • Directs the Infection Control Process, which includes effective surveillance, actual and potential problem identification and resolution, and monitoring of clinical practice, and consistent reporting.
  • Facilitates the investigation and resolution of patient complaints and grievances. Initiates and/or reviews correspondence to patient/family following established timelines.
  • Collaborates with hospital Chief Medical Officer to actively participate in sustaining a medical staff that is knowledgeable of clinical outcomes, quality data and culture of transparency and patient safety, fosters collaboration among physicians and associates.
  • Analyzes occurrence data for frequency and severity of events. Identifies trends necessitating intervention and works with leadership in planning and implementing actions to address identified issues. Tracks and reports to the FDA, and other entities, any medical device related events according to the requirements of the Safe Medical Device Act.
  • Works with physicians and other client staff to identify an appropriate resolution to complaints.

Board is Aware and Approves of Performance Improvement Actions & Outcomes for the Delivery of Safe Patient Care

  • Develops a comprehensive quality and patient safety plan to include specific measures and accountabilities and a comprehensive reporting program to demonstrate and anticipate outcomes to administration, leadership and management, including short term and long-term goals for quality improvement
  • Oversees the quality program that incorporates the evaluation of quality across the continuum of care from outpatient setting to acute care inpatient setting, including coordinating the data collection, analysis and reporting processes and systems, policies and procedures for quality management.
  • Directs and supervises maintenance of nursing department facilities, equipment, supplies, and areas, and assures compliance with established standards and regulatory requirements.Inspects all departmental areas on a regular basis and initiates corrective action and follow up.
  • Develops annual quality plan.Reports monthly to management committee on quality.Reports quarterly to the Board on progress against plan.

Approved Budget and Productivity Standards

  • Responsible for cost controls to insure maximum effectiveness of funds expended from approved departmental budgets.
  • Oversees the development of operating and capital budget for assigned areas of responsibility and creates accountability for compliance of approved budget and productivity standards within each service.
  • Establishes and promotes the appropriate structure for clinical nursing services by analyzing the efficiency and effectiveness of nursing allocations and deployments, ensuring that nursing services are well-coordinated with other clinical departments of the organization.
  • Provides oversight of patient care resources; monitoring capital and operational budgets; establishing systems for proactive budget variance identification and correction.
  • Ensures financial, material, people and technological resources are allocated to achieve optimal results.

Key Competencies

Strategic Agility: Sees ahead clearly; can anticipate future consequences and trends accurately; has broad knowledge and perspective; is future oriented; can articulately paint credible pictures and visions of possibilities and likelihoods; can create competitive and breakthrough strategies and plans.

Building Organizational Talent: Anticipates talents, skills and knowledge that will be needed in the organization; seeks out opportunities to grow people’s capabilities to match those needs; improves the results of others by identifying areas of performance strengths and development opportunities, by providing coaching, mentoring or development opportunities, and by providing clear, behaviorally specific feedback to team members and subordinates; creates a learning environment that ensures associates realize their highest potential, allowing the organization as a whole to meet future challenges.

Driving Execution: Sets and maintains high performance standards for self and others that support the organization’s strategic plan and holds self and other team members accountable for achieving results; ensures organizational systems, processes and people are aligned to support strategic objectives; regularly evaluates self and team on goal attainment, processes used to achieve goals, and competitive benchmarks.

Managing Change: Helps employees develop a clear understanding of what they will need to do differently as a result of changes in the organization; establishes structures and processes to plan and manage the orderly implementation of change; helps individuals and groups manage the anxiety associated with significant change; facilitates groups or teams through the problem-solve and creative-thinking processes leading to the development and implementation of new approaches, systems, structures and methods.

Inclusion: Relates well to a wide variety of diverse styles, types and classes; open to differences; effective up, down, sideways, inside and outside; builds diverse networks; quick to find common ground; treats differences fairly and equitably; provides an environment where all employees feel welcome to contribute their full range of skills, ideas and opinions; demonstrates sensitivity to and respect for the diverse cultural backgrounds and practices of customers, regulatory agencies, and staff.

Total Work Systems: Is dedicated to providing organization-wide common systems for designing and measuring work processes; seeks to reduce variances in organization processes; delivers the highest quality products and services which meet the needs and requirements of internal and external customers; is committed to continuous improvement through empowerment and management by data; leverages technology to positively impact quality; is willing to re-engineer processes from scratch; is open to suggestions and experimentation; creates a learning environment leading to the most efficient and effective work processes.


Education & Experience

Bachelor’s degree in nursing. Masters’ degree in nursing or related field preferred. At least five years of clinical experience in an acute care setting. Familiar with TJC standards and 10NYCRR. Managerial experience preferred.

Licenses and/or Certifications

  • RN with current NYS license
  • Maintains clinical credentials and competencies to be able to work clinically
  • Certification in healthcare quality, six sigma, or TQM preferred


  • Ability to interact, work with and support the activities of the physicians.
  • Demonstrated management skills:especially strong in planning, organizing, staff development, communications, decision-making and interpersonal skills.
  • Ability to demonstrate leadership, managerial ability, good interpersonal relationships, and the application of sounds administrative principles
  • Excellent organizational, verbal and written communication skills
  • Ability to problem-solve, independently and in group setting
  • Leadership and team-building skills
  • Computer literacy
  • Ability to work with a variety of disciplines, cultures and levels of staff throughout the organization
  • Self-directed, self-motivated, and able to motivate others
  • Ability to work under stressful situations and accommodate irregular and long hours.
  • Ability to coordinate multiple demands and meet rigid timelines

Language Ability

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Math Ability

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages. Ability to apply concepts of basic mathematics.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Physical Demands

While performing the duties of this job, the employee is regularly required to sit; use hands to handle or feel objects, tools or controls; reach with hands and arms. Specific vision abilities include close vision and ability to adjust focus. The employee must occasionally lift and/or move up to 10 pounds. Must be able to communicate on the telephone.


Slight potential for exposure to infectious diseases and bloodborne pathogens.

Interested candidates must apply directly to .

This position is not part of the University of Rochester/ University of Rochester Medical Center. The final candidate will be employed by and subject to St. James Hospital pay, benefits and employment policies and practices.

Job Title: Chief Nursing Officer

Location: Medical Faculty Group

Job ID: 209035

Full/Part Time: Full-Time