The Chief Quality Officer: Evolution of Leading Quality

Twenty years ago, the title “Chief Quality Officer” barely existed in healthcare. Today, many health systems have one. But having a CQO and having a discipline of executive quality leadership are two different things.

The evolution from investigating individual errors to building systems of improvement mirrors the journey many CQOs have taken—from quality inspection to strategic leaders. Understanding this evolution reveals what the role requires now and where it’s headed.

The Quality Inspection Era

When I became the leader responsible for quality at a large healthcare organization 25 years ago, my job was to investigate. The assumption was clear: systems were sound, mistakes were human. Good people deviated from protocol through lack of knowledge or carelessness. We investigated, found root causes, counseled, educated.

But whenever I pulled a sample of records, a pattern emerged. The same mistake appeared multiple times—unreported, uncaught. The person being counseled wasn’t the problem. They were revealing a broken process. We were educating individuals for system failures that would continue regardless.

Fixing one process didn’t solve the larger issue. Each process sat within an integrated system. There was always more to fix. And we had no method for systematic improvement.

This experience wasn’t unique. Across healthcare, organizations were creating quality leadership roles with widely varying structures, reporting relationships, and expectations. Training focused on tools and methods. Projects were nominated locally. Improvement remained episodic. Most efforts stalled.

Making the Case for a New Kind of Leader

Professor Sir Nick Black articulated what many of us were experiencing. Just as no board would expect competent financial management without a finance director, he argued, quality deserves dedicated executive leadership. “We need chief quality officers with vision to lead, inspire staff and facilitate rigorous assessment and improvement of quality throughout their trust,” he wrote.

His insight was that while quality remains everyone’s responsibility, medical and nursing directors—despite achievements—were too constrained by competing duties and crisis management to lead the transformation healthcare needed.

The argument resonated. Since 2017, demand for CQOs has increased fivefold, driven by value-based reimbursement, public quality reporting, and post-pandemic urgency around patient safety.

Discovering What the Role Actually Required

In 2015, I led research to understand the current state of executive quality leadership through literature review and interviews with CQOs and experienced improvement leaders. We used grounded theory to identify patterns across diverse organizations.

The findings were revealing. Most CQOs were first or second-generation in the role. First-generation leaders had positions designed around immediate organizational needs and their own capabilities. Second-generation leaders inherited those designs.

Common responsibilities appeared everywhere: quality metrics, root cause analysis, accreditation. But so did random assignments—security, disaster preparedness—that exposed how undefined the role remained. An assumption persisted that CQOs should be clinicians, preferably physicians, yet evidence didn’t support this. Non-physician leaders were equally effective.

When asked about improvement methods, CQOs described combinations of Kaizen, Lean, PDCA, and RCA—mashups rather than integrated approaches. The pattern was consistent: lots of projects, inconsistent results, limited spread.

The role existed, but the discipline didn’t. What these leaders needed was a professional development pathway and shared framework for building quality systems.

Developing a Profession

The research led to creating IHI’s Chief Quality Officer Program, which I led for the first cohorts alongside experienced CQO faculty. We designed curriculum around Juran’s framework—planning, improvement, control—and developed a driver diagram outlining five key drivers: infrastructure, culture, planning, improvement, and sustainment.

The cohorts brought together dozens of current and aspiring CQOs. Beyond the curriculum, what emerged was powerful: peers discovering they weren’t alone in their challenges, sharing lived experiences, and gaining frameworks they could apply immediately.

Years later, many from those cohorts still collaborate and use the frameworks we developed together.

The Expanding Scope

The CQO role today looks markedly different than a decade ago. One leader describes it as the “all other duties as assigned bucket”—when issues don’t fit neatly elsewhere, they come to quality. The scope spans clinical processes to finance-related challenges.

Some CQOs now view the position as preparation for the CEO role. As one chief safety, quality and patient experience officer notes, the role requires understanding “not only how to be influencers of culture and change management, but we have to know improvement tools; what tools to use for what problem we’re trying to solve.”

Research on top-performing organizations confirms this evolution. While credentialing and case management have largely moved out of quality departments, new functions have integrated in. Patient safety and infection control appear in 88% of top performers’ structures. Data analytics appears in 75%, ambulatory care in 63%—functions barely present in quality departments in 2012.

The structures have matured. Training programs exist. Shared methods are more common. Project portfolios are active.

The Leadership Gap

Yet a gap persists between having quality structures and leading systematic improvement. CQOs tell me they have activity but struggle to achieve consistent results. They have projects but need systematic approaches. They have trained staff but need organizational capability that produces sustainable change.

This is the shift from coordinating quality activities to leading quality systems. It requires different capabilities than what got organizations to this point.

The work now is building three things simultaneously: systems that enable improvement work to produce results, leadership learning systems that develop capability throughout the organization, and alignment between improvement efforts and strategic priorities.

This means shifting from episodic projects to integrated work. From local initiative selection to strategic alignment. From tool training to building organizational capability. From measuring activity to demanding results.

Meeting the Moment

My path—from early CQO experiencing these challenges, to researching the role, to developing professional pathways, to now supporting organizations building their systems—has shown me what works at this stage of evolution.

Quality as an Organizational Strategy provides a method for this work. It integrates capability-building with achieving results through strategically aligned improvement. It establishes leadership learning systems and five interdependent activities. The approach scales with organizations and provides structure while remaining adaptable to context.

For CQOs who have established quality structures and are ready to lead systematic transformation, this is the work. Quality is every leader’s job. CQOs provide the leadership to build and use the systems that make quality systematic.

The discipline has matured beyond the role. The question now is how CQOs will lead the next evolution—from coordinating quality to transforming how their organizations work.

David M. Williams, Ph.D. works with leaders and improvement teams to learn and apply Improvement Science to achieve results and adopt quality as a strategy. He is coauthor of Quality as an Organizational Strategy and The QOS Field Guide.