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As a member of the executive leadership team, the Chief Quality and Medical Officer (CQMO) 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:

Quality & Safety

· As the senior physician executive, the CQMO collaborates with the executive team and Medical Staff leadership to develop and maintain a comprehensive strategy to monitor, evaluate and improve the quality of patient care, patient experience, and implement processes that sustain reduction in harm and continuously improve safety outcomes throughout the entity. Being an executive leader and sponsor for continuous quality and safety performance improvement is key to this role.

· As the senior physician executive, the CQMO collaborates with the executive team and Medical Staff leadership to develop and maintain a comprehensive strategy to monitor, evaluate and improve the quality of patient care, patient experience, and implement processes that sustain reduction in harm and continuously improve safety outcomes throughout the entity. Being an executive leader and sponsor for continuous quality and safety performance improvement is key to this role.

· The CQMO will utilize their expertise and experience to proactively identify opportunities and drive the entity in working towards highly reliable quality and safety outcomes. This physician executive will have comfort and experience with multi-disciplinary teams and with collaborative, horizontal approaches to building care and quality. This person may also be asked to serve on system level committees as a representative of the entity or based on the CQMO’s expertise.

· Works to lead and be responsible for contributing to the achievement of hospital channel key performance indicators (KPIs) and key performance measures (KPMs) related to clinical quality improvement and harm reduction, as well as operating margin through management of costs associated with avoidable harm and maximizing value-based purchasing reimbursement. Understanding and improving on utilization management benchmarks as it improves the overall total cost of care is an important aspect of this role.

· Responsible for the management and oversight of the entity’s Infection Prevention, including the threat of emerging diseases, multi-drug resistant organisms, and maintenance of Joint Commission standards in this realm. The CQMO will work closely with the system leaders for Infection Prevention.

· The CQMO will assist the hospital President in the recruitment of new medical staff based on quality and safety.

· This role will also assist in making decisions regarding new technology based on clinical need, evidence-based practice, and the achievement of excellence in clinical quality, safety, and patient experience related to that particular specialty or service line.

· The CQMO has executive oversight regarding care management to address length of stay, patient flow, timely discharge, avoidable readmissions and avoidable post-discharge emergency room visits, and clinical outcomes management; provides oversight to physician advisors working with case management; aids in the development of standardized order sets, protocols, and clinical pathways to support the design of effective patient care delivery models, and works with case management and performance improvement to monitor use of approved care pathways and to facilitate adoption by the medical staff.

· The CQMO oversees development of physician performance measures and aids in distribution and explanation of the performance measures to department chairs and medical staff members. The CQMO assures that the Medical Staff leaders have complete and accurate data, know how to interpret the data, and appreciate the implications of such findings. The CQMO provides assistance as the medical staff makes its decisions and takes action as appropriate. Also, the CQMO helps to educate physicians and other care providers and assumes a role in developing and monitoring practice patterns for physicians. The CQMO has executive oversight of Quality and Risk Management to address issues such as, sentinel events and compliance with regulatory agency requirements.

· The CQMO will be a source of information about developments in CMS, value based medicine, and public reporting of quality. The Medical Staff will be provided with periodic updates of national trends and local initiatives that will have an effect on their patient care decisions.

Physician Recruitment, Physician Leadership, and Medical Staff Development

· The CQMO oversees the design and implementation of effective physician recruitment, orientation and retention activities that will attract and keep new physicians. In addition, the CQMO ensures a smooth and efficient application process for all new applicants to the medical staff and assists the medical staff in its application of credentialing, privileging, and reapplication activities. The CQMO partners with the President to inform and support entity physician contracting.

· This physician executive engages and supports physicians who are responsible for executing plans; leverage the full talent and expertise of physician leaders through mentoring and attention. Recognize and identify the collective and mutual value of the unique partnership between the private/voluntary and employed physician staff; help to shape and strengthen the clinical enterprise by creating synergies between the various medical staff entities and its physician constituents. The CQMO will set collaborative expectations with physician leaders, the medical executive committee, and department leads and expect accountability to achieve on collective goals and objectives.

· The CQMO will model clear and consistent communication among appropriate parties. The CQMO will seek input and involvement from the Medical Staff and provide the Medical Staff with information concerning the rationale and impact of decisions made by the senior management team, while also translating the concerns and issues of the medical staff relative to management’s decision making.

· The CQMO is expected to encourage effective and open communications and cooperative interactions with Medical Staff members, administrative leaders and community leaders to support the system’s growth and service initiatives. Additionally, the Chief Quality & Medical Officer will engage and support nursing leadership excellence, collaborate on nursing patient care outcomes, especially as it relates to the clinical operations involving the medical staff and service lines.

Management/Strategy

· The CQMO participates in strategic planning at several levels in the organization: as an integral part of the executive management team that develops plans, strategies and budgeting for organizational success, and in developing annual plans within medical affairs and assisting the Medical Staff leadership and clinical chiefs as they consider the hospital’s objectives and its plans for implementation of new clinical initiatives, medical equipment, technology and construction.

· The CQMO participates in the strategic planning process. The Chief Quality & Medical Officer will ensure medical staff goals and objectives are in alignment with facility goals and initiatives and facilitates steering committees of the medical staff. Oversee systematic ideation programs to solicit clinical constituents and innovation opportunities, adhere to baseline criteria or thresholds for evaluation, review physician proposals and develop funding recommendations.

Medical Affairs

· The Medical Staff office and its medical affairs functions are the responsibility of the CQMO. The CQMO serves as a member of the Medical Executive Committee or Medical Board. The CQMO coordinates with the CMO Reliable Health and credentialing committee to develop appropriate credentialing and privileging criteria. Additionally, the CQMO assures that efficient and effective systems are in place and guides their operation. The CQMO provides administrative support to and facilitates committees of the medical staff, provides advice and guidance to the officers of the Medical Staff. This physician executive also assures that medical staff leaders have necessary information to make decisions, implement medical care policies, and assure that appropriate bylaws and procedures are in place. The CQMO works with the appropriate administrative staff and medical staff to facilitate the peer review process and is the executive champion for adjudicating serious safety events.

· The CQMO will be a source of information about developments in the new state board and federal updates in healthcare and other issues affecting the practice of medicine. The Medical Staff will be provided with periodic updates of national trends and local initiatives that will have an effect on their patient care decisions.

Professional Experience/Qualifications:

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.

• 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.