Job Summary Approximately 50% time will be spent on CMO responsibilities and other 50% time on other responsibilities as assigned.
Position will participate in strategic planning for the network and identify appropriate system level goals and targets. Position has primary responsibility for the implementation of programs that drive a culture of safety and improve the quality of medical care delivered at the facility. The CMO collaboratively leads and implements strategies to ensure that outstanding quality outcomes and exceptional patient experience are delivered in a safe manner at a reasonable cost. Collaborates with the Medical Staff Leadership to provide oversight of the care provided to patients. Serves as a liaison to the facility-based Utilization Review Manager, facility-based Clinical Documentation Improvement Specialists, and facility Coding Specialist and Risk Manager. Works with the hospital-based medical directors and department chairs, this position has the authority to intervene with individual physicians when there are clinical or behavioral issues. Serves as an executive sponsor and mentor for a network service line, leading a network quality initiative, participating in specialty task forces and other duties as assigned. Each hospital CMO will work closely with other identified executives and medical directors in carrying out identified network-wide responsibilities. Special projects or unique local responsibilities may also be added where necessary.
Serves as part of the network-wide Hospital Senior Management Team. Actively participates and attends the network-wide CMO and Quality Oversight meetings, as assigned. Collaborates with other hospital CMOs to standardize programs and clinical care where appropriate across the Network. Participates in strategic planning for the network, and identify appropriate system level goals and targets.
Reviews, in conjunction with the appropriate medical staff committees and the quality QES Department, unanticipated outcomes, deaths, transfers, patient safety indicators, controversial cases and selected complications.
Provides leadership to the hospital campus related to the formal medical staff in collaboration with the SVP/Chief Physician Executive. As part of this responsibility, the position will: a.Regularly attend the Medical Executive Committee and Credentials Committee meetings. b.Regularly attend facility Department Committee meetings. c.Meet regularly with Department Chairs. d.Participated in peer review activities. e.Assures compliance with CMS and ADHS standards, rules, and regulations. Participates in DNV surveys and assists with resolving non-conformities f.In events involving serious adverse outcomes, the CMO will serve as a just-in-time coach for clinicians prior to disclosure to patients and families. The CMO may be asked to participate directly in the disclosure of an event involving hospital-based system error.
Reviews individual physician performance related to drug, blood products, and supply usage. Also reviews the use of Laboratory and Radiology testing. Provides feedback to individual physicians when appropriate. Intervenes with individual physicians when outliers are identified. Regularly reviews the utilization statistics of the hospital, including the hospitalists and other physician groups providing care in the hospital setting. Develops educational programs to improve performance where appropriate.
Collaborates with medical staff leaders to address individual physician quality and behavioral issues: a.Recommends to the Medical Leadership and Chief Physician Executive the suspension of privileges when appropriate. This includes taking immediate action where the care provided by a physician places patients in immediate danger. b.Continuously reviews the medical staff's peer review system and its performance. Assists the medical staff leadership in improving performance. c.Assures compliance by all medical staff physicians with Bylaws, Rules and Regulations, and Policies of the Medical Staff at HonorHealth. Resolves, or assists in the resolution, of issues and needs that arise among physicians pertaining to the care of patients. d. Intervenes when necessary with individual clinicians to assure compliance with regulatory guidelines and assure the best clinical care for patients.
Leads performance improvement initiatives, especially those projects impacting the hospital's performance on Value Based Purchasing, including outcome measures such as mortality, readmission rates, healthcare acquired conditions, patient experience, and costs per case. Develops service standards and quality metrics job descriptions and clear accountabilities for medical directorships and key physician contracts. Collaborates with Pharmacy Leadership to develop and enforce evidenced-based, cost-effective drug formulary decisions. \
Partners with the CEO, Vice Presidents, and Contracting Department to develop service standards and quality metrics job descriptions and clear accountabilities for medical directorships and key physician contracts. Facilitates improved physician satisfaction and address physicians concerns, ensure coordination of clinical services and to ensure excellent working relationships exist between physicians and nursing. Serves as medical liaison to independent community physicians.
Provides matrix supervision of Case Management facility-based Safety and Quality Consultant and Infection Preventionist. Provide feedback to individual physicians regarding their performance and identifies opportunities to improve performance where appropriate.
Collaborates with the Chief Academic Officer to assure appropriate teaching opportunities for residents and medical students and adherence to regulatory requirements. Facilities with Residency Programs the CMO will collaborate with the Chief Academic Officer to assure appropriate teaching opportunities for residents and medical students and adherence to regulatory requirements.
Provides leadership for ED Call for all specialties, as well as transfers to the in-patient service: a.Assures that call schedules are in place at the hospital and transport agreements are in place for all specialties. b.Coordinates the call for admissions requiring hospitalist services. Collaborates with Hospital Administration in order to assure that EMTALA regulations are followed. c.Assists in the development and implementation of admission and transfer protocols, policies, procedures and guidelines.
Performs other duties as assigned.
Internal Number: 2018-12400
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We are a non-profit, local healthcare organization known for community service and outstanding medical quality. Our organization encompasses five acute care hospitals with approximately 10,500 employees and 3,100 volunteers, urgent care centers, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.