·        Ensures processes are in place to ensure compliance with Quality and Performance Improvement and as applicable with, Patient Safety, and Accreditation functions, in partnership with the medical staff. 
·        Ensures hospital compliance with accreditation, licensing and regulatory agencies.
·        Assure and observe compliance with the policies and procedures outlined with full regard for the identification and reporting of incidents, potential hazards and other relevant information in a timely manner.
·        Provides hospital staff specific training, as needed, regarding quality activities or procedures.
·        Leading the effort to develop the technology infrastructure needed to support quality improvement programs.
·        Leading the effort to develop the technology infrastructure needed to support quality improvement programs.
·        Ensures processes are implemented to evaluate and identify opportunities for improvement in the provision of high quality, safe and resource effective medical care to patients.