As a member of the executive leadership team, the Chief Quality and Medical Officer (CQMO) PRN is responsible for providing clinical perspective, knowledge, experience, and leadership to ensure collaboration and alignment between the entity, system and the medical staff. The CQMO facilitates communication with the Medical Staff, oversees and is responsible for the entity's quality program, the overall quality of care to include patient experience and appropriate clinical utilization provided by the Medical Staff. This executive expects and facilitates participation of the Medical Staff in quality initiatives, clinical resource utilization, physician performance monitoring, and use of clinical information technology, medical education and clinical outcomes.
The CQMO assists with the recruitment and retention of physicians and assists the medical staff in its application of credentialing, privileging, and reapplication activities. In conjunction with the respective system officers, the CQMO acts as the entity's liaison for facilitating and coordinating the use of clinical information technology. The Chief Quality and Medical Officer will provide leadership over physician engagement and integration activities.
Oversight of the clinical aspects of operations is key to this role.
Key internal relationships include executive and physician Regional Leadership (to include the leadership of the organized medical staff, physician representatives of specialty group practices, as well as the "informal" leaders of the medical staff) and corporate leadership in strategy and business development and information technology. Other stakeholders related to quality outcomes include the Chief Nursing Officer and others associated with the clinical and operational multi-disciplinary team.
Key External relationships include the hospital channel CQO, Reliable Health CMO/CNE dyad as well as other system leaders including Regulatory Operations, Infection Prevention, and Infectious Disease.
The Chief Quality & Medical Officer is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards of the state, the federal government, hospital bylaws and accrediting bodies.
Essential Functions:
The PRN Chief Quality and Medical Officer ('PRN CQMO') shall assist with planning, coordinating, and overseeing the administrative functions of the Hospital. These shall include but are not limited to scope of services, development of call schedules, staffing levels, facility space, budget, financial performance, and program feasibility, as more specifically described herein.
Clinical Guidance
The PRN CQMO shall provide clinical guidance and serve as a resource with respect to clinical issues. Clinical guidance includes, but is not limited to:
Develop and implement clinical protocols, policies and procedures.
Become and remain informed on developments in evidence-based clinical best practices.
Update and advise physicians and hospital clinical personnel on evidence-based clinical best practices.
Serve as a resource to other physicians to facilitate the provision of quality care.
Advise Hospital and medical staff on scope of services offered in the Hospital; * Provide input regarding clinical staffing levels.
Review and provide assistance in resolution of patient complaints/grievances of a clinical nature.
Monitor Hospital data to promote quality and efficiency of clinical services.
Understand entity key performance indicators and how PRN CQMO's duties relate to them.
Med Staff Relations
PRN CQMO shall serve as a liaison between Hospital administration and personnel and physicians within the Hospital. PRN CQMO will also support elected medical staff leadership in the Hospital. These responsibilities include, but are not limited to:
Assistance with orientation of physicians to the Hospital.
Conflict resolution between:
o medical staff members
o physicians and Hospital personnel
o physicians or Hospital personnel and patients and/or families
Collegial intervention with physicians when potential behavior or quality issues are identified.
Reasonable participation on medical staff committees, including peer review activity, when requested.
Financial Performance
The PRN CQMO shall provide input regarding financial decisions that affect the Hospital, including, but not limited to:
Participate in annual budget preparation.
Review financial performance and program feasibility.
Suggest and/or support and monitor implementation of efficiency, productivity and cost-containment guidelines that promote appropriate utilization of resources.
Technology Assessments
The PRN CQMO shall participate in technology assessment, including, but not limited to:
Evaluation of needs/requests for new or additional facilities or equipment.
Development of function and technical specifications for capital equipment needs.
Evaluation of vendor proposals.
Other Activities:
PRN CQMO shall perform such other administrative activities as Hospital may reasonably request from time to time, e.g. participate on Hospital committees and in Hospital performance improvement activities. It is understood that the PRN CQMO's duties do not encompass any direct patient care falling within the scope of the Texas Medical Practice Act, e.g. the diagnosis and treatment of patients. It is further understood that some of the services provided by the PRN CQMO may be conducted at the request and/or direction of one or more committees of the Hospital. In such case, the PRN CQMO will assist the applicable committee in carrying out its functions, and those services the PRN CQMO provides will be confidential and privileged.
Program Specific Responsibilities:
PRN CQMO has the following program specific responsibilities related to administration of the Hospital.
The Physician Party will serve in the role of PRN CQMO to be mentored and to gain experience in this role and thereby, enable the Physician Party to assume the PRN CQMO role when the current PRN CQMO retires.
The Physician Party shall be responsible for Infection Prevention and special projects as assigned by the PRN CQMO or Hospital President.
The PRN CQMO shall work eight (8) hours per week.
Individuals must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This role requires the ability to solve problems, think outside the box, and be resourceful; must be result-oriented, a quick learner and a self-starter. The requirements listed below are representative of the knowledge, skill, and/or ability required to build THR's culture for action.
M.D. or D.O. Board certification in a medical or surgical specialty recognized by the American Board of Medical Specialties or American Osteopathic Association required.
Master's Degree, MBA, MPG, or other advanced management degree is highly desirable.
Board certification in a medical or surgical specialty recognized by the American Board of Medical Specialties or American Osteopathic Association required upon hire.
5 years' experience in medical management as a CMO, CQO, or VP Medical Affairs or equivalent experience with evidence of progressively greater responsibility including a significant component of clinical performance improvement and patient safety accountability required.
Demonstrable and credible experience in clinical practice so that s(he) will be able to relate credibly to a diverse and exceptionally trained medical staff.
Progressive leadership in healthcare and medical staff activities with clear achievements in these domains.
Experience and achievements when accountable for Quality, and Patient Safety and Performance Improvement programs in a hospital setting.
Experience with clinical informatics and/or an electronic health record.
Experience and achievements executing Quality, Patient Safety and Performance Improvement programs by building consensus through complex organizational constituencies and/or stakeholders - in other words, the ability to lead through influence as well as authority. Ideally, some or all of this experience will have been obtained in a complex, multi-hospital system of at least five to seven hospitals and a diverse medical staff community.
Clear evidence of the ability to both be an effective member of an executive team and build formal and informal relationships in order to achieve specific goals and objectives.
An appetite for managing change and a tolerance for ambiguity. In other words, the ability to 'stay on task' in a complex, fast moving organization.
A passion for data, data analysis, and a willingness to establish and meet or exceed objective parameters of performance.
Evidence of an ability to communicate effectively with diverse constituencies and stakeholder groups or individuals (orally and in writing) and to project integrity and inspire confidence.
Lead by example and motivate and inspire others to improve care in a safe, contemporary, and compassionate manner.
Clear evidence of the ability to effectively adapt leadership skills in different environments/cultures.
Texas Health requires a resume when an application is submitted.Employment opportunities are only reflective of wholly owned Texas Health Resources entities.
We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
