Job Description

  • Requisition ID
    2018-7227
    Shift
    01 - Days
    Department
    Hospital Admin
    Facility
    John C Lincoln Med Center
    Position Type
    Regular Full-Time
    Physical Work Location and New Employee Orientation Location : Address
    250 E DUNLAP
  • Overview

    HonorHealth is a non-profit, local healthcare organization known for community service and outstanding medical quality. HonorHealth encompasses five acute care hospitals with approximately 11,500 employees and 4,500 volunteers, over 70 primary and specialty care practices, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.

    HonorHealth is a leader in medical innovation, talent and technology with a genuine commitment to your growth. The health system's vibrant careers take place in an environment filled with opportunity and respect because we see the HONOR in you.

    Qualifications

    Education
    Additional formal training in quality improvement, patient safety , risk management, or medical management required Required

    Experience
    Demonstrated leadership capabilities Required

    Licenses and Certifications
    Required

    Responsibilities

    Job Summary
    The Hospital Chief Medical Officer (CMO) is the physician executive who 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. The CMO is part of the hospital executive team partnering with the CEO, CNO, and VP of Operations to ensure high value and appropriate care is delivered in the hospital setting, as well as transitional care in the community.

    The Hospital CMO's responsibilities include collaborating with the Medical Staff Leadership to provide
    oversight of the care provided to patients. The CMO will directly supervise the hospital-based medical directors (Hospitalists, Emergency, Intensivists and others as appropriate per facility), and will have matrix supervision of the facility-based Safety and Quality Consultant, the facility-based Infection Preventionist, the facility Manager of Case Management, and facility-based Medical Staff Office personnel. The CMO will serve as a liaison to the facility-based Utilization Review Manager, facility-based Clinical Documentation Improvement Specialists, and facility Coding Specialist and Risk Manager. Working with the hospital-based medical directors and department chairs, the Hospital Chief Medical Officer has the authority to intervene with individual physicians when there are clinical or behavioral issues. The CMO will serve as the facility based Patient Safety and Quality Officer. The CMO will partner with the facility based quality and Safety Consultant, Risk Manager, and CNO to respond to and investigate adverse events, then develop and implement appropriate action plans. The CMO will partner with the CEO to address physician concerns and will be the point person to design and develop key physician contracts in collaboration with the CEO and Contracting Department.

    The Hospital CMO reports to the Network CMO and Vice President of Quality and the facility CEO in a matrix relationship. The facility CMO collaborates with the Network and other hospital CMOs to standardize programs and clinical care where appropriate across the Network. The CMO will participate in strategic planning for the network and identify appropriate system level goals and targets.

    Network responsibilities will be assigned by the Network CMO based on interest and experience level, identified needs of the organization, and the size and complexity of the primary facility. This may include serving 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 at the discretion of the facility CEO in collaboration with the Network CMO. Approximately 80% of the CMO's time will be spent on facility responsibilities and 20% on Network responsibilities.
    • 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 the Network CMO and 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.
    • 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 and works with Coding and Documentation Improvement Specialists to ensure appropriate and timely physician response to coding queries and proper documentation of care rendered by physicians.
    • 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.
      a.Assures compliance with CMS and ADHS standards, rules, and regulations. Participates in DNV surveys and assists with resolving non conformities
      b.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.
      e.Oversees the facility approach to adverse events and ensures that appropriate local action plans are developed and acted upon in a timely manner. Ensures that network-wide action plans identified from events occurring at other HonorHealth facilities are fully implemented. Participates in Root Cause Analysis of Serious Adverse Events occurring at the facility and on the Sentinel Event Determination Team. Supports and encourages reporting of patient safety concerns throughout the organization though the use of a non-punitive error reporting system and walk rounds.
    • 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:

      c.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.
      d.Continuously reviews the medical staff’s peer review system and its performance. Assists the medical staff leadership in improving performance.
      e.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.
      f. Intervenes when necessary with individual clinicians to assure compliance with regulatory guidelines and assure the best clinical care for patients.
    • Collaborates with Pharmacy Leadership to develop and enforce evidenced-based, cost-effective drug formulary decisions. Assists with order set development and with the investigation of medication administration errors. Meets with individual physicians to enforce Antimicrobial Stewardship Guidelines.
    • Directly supervises the Medical Director or leaders of the contracted hospital-based specialties including, hospitalists, intensivists, emergency and palliative care groups, to ensure appropriate coordination of the care provided by hospitalists, emergency department, and the intensive care units. Schedules regular meetings with Department Chairs and hospital-based Medical Directors to review individual and group performance on key quality and patient safety indicators and mentor and coach these physician leaders.
    • 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. Assures that physicians at the hospital have strong, collaborative relationships with Case Management. Assists with coordinating the care of patients when communication issues arise between the physicians and patients/families. Works with Case Management and Utilization Management to resolve difficult discharge issues and ensure appropriate use of hospital resources.
    • Participates with CME planning for the hospitals with the Network Chief Physician Executive. In 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.
    • Partners with the CEO, Vice President of Operations, and Contracting Department to develop service standards and quality metrics job descriptions and clear accountabilities for medical directorships and key physician contracts.
    • 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.
    • Collaborates with Hospital Executive team to facilitate 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.
    • Serves as the campus liaison to the Senior Vice President, Population Health for patient care issues across the continuum, Chief Medical Information Officer (CMIO), Physician Executive for Medical Staff office issues and CMO and Medical Director of Quality for the Honor Health Medical group regarding outpatient and transition care issues.



    It is the policy of HonorHealth to provide equal opportunity in employment. Selection and employment of applicants will be made on the basis of their qualifications without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, veteran status or any other legally protected status.

    Please review the Equal Employment Opportunity poster.

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