The Chief Medical Officer (CMO) reports directly to the President and CEO of the Hospitals and the Chief Medical Officer of Steward Health Care System. Within established organizational and departmental policies and procedures, the CMO develops an effective medical staff to serve the needs of the community and monitors and improves the quality of care in the Hospitals and the community. The CMO is a member of the executive team of the Hospitals, who not only manages a portion of the organization, but also performs a key role in relating hospital functions, decisions, and policies to the medical staff, as well as relating medical staff opinions, attitudes, preferences, and needs to the Hospitals leadership and governing body. The CMO serves as a resource to the medical staff, chiefs, and staff in credentialing, reappointment, peer review, and quality review.
The CMO is directly responsible for credentialing, medical education, quality assurance and improvement, and patient safety / risk management. He/she will work with the clinical chairs in the development of departmental vision, growth plan, and quality agenda. The CMO will coordinate and facilitate the development of cross-discipline programs and hospital-wide initiatives, as well as collaborate with the President and key senior team members on hospital/physician alignment, service line development and profitability, and new technology.
The CMO will serve as a liaison to the medical staff and hospital administration, and in collaboration with the larger team, creates a culture of respectful, mutual support, and extraordinary quality and service consistent with the Hospital's strategy and values.
Quality and Safety, and Patient Experience of Care:
• Ensures implementation of Quality and Safety Plan and annual goals through interface with Medical Executive Committee, as well as other committees and workgroups.
• Chairs Patient Safety Triage Team.
• Chairs Quality and Safety Committee.
• Ensures current processes are effective and addresses shortfalls through assessment, development and implementation of protocols and practices.
• Is accountable for continuous performance improvement and achievements of goals on internal and external measures.
• Reviews all events in the incident reporting system and participates in root cause analysis as needed, identifying and overseeing implementation of corrective actions.
• Analyzes and acts on safety trends.
• Oversees the supervision of the patient advocate, risk and regulatory managers, performance improvement specialists, and infection control staff.
• Facilitates the involvement of medical staff members in the peer review process and works to improve the coordinated efforts of all medical staff departments to continually and systematically monitor and improve care.
• Monitors quality and safety, patient satisfaction, risk management, and utilization review, and develops performance improvement plans.
• Works with clinical documentation specialists, coders, and medical staff to ensure complete and accurate documentation.
• Develops agenda for Medically related Committees of the Board.
• Ensures regulatory readiness, reviewing, and implementing policies for hospital and medical staff; has a leadership role in Policy Committee.
• Takes an active role in regulatory readiness (e.g. Joint Commission, CMS, DOH, DMH, OSHA, FDA, etc.).
• Is accountable for completeness of medical record documentation by medical staff.
• Is accountable for timely adoption and education related to new policies and existing policies.
• Submits timely reports to regulatory agencies as required
Medical Staff Office:
• Supervises and meets regularly with the Director, Medical Staff Office.
• Serves as resource regarding credentialing or medical staff issues.
• Ensures medical staff is fully credentialed.
• Ensures Joint Commission readiness for medical staff issues, including focused and ongoing Professional Performance Evaluation compliance.
• Ensures ongoing compliance with medical staff bylaws.
Medical Executive Committee and Peer Review:
• Ensures adherence to timely and complete Morbidity and Mortality Rounds in all departments, reviews reports, and refers to Peer Review when appropriate.
• Serves on and staffs Medical Executive Committee.
• Addresses issues related to medical staff affairs.
• Supports Clinical Quality Committee (Peer Review).
Care Coordination and Management:
• Actively participates in care management to ensure appropriate length of stay, appropriate level of care, and minimize preventable readmissions.
• Serves as physician resource on as needed basis for nursing, leadership, case management, and pharmacy.
• Actively participates in the implementation, staff education, and ongoing evaluation of the electronic health record.
• Leads utilization review committee.
• Participates in throughput flow improvement work.
New Program Development:
• Supports coordination of clinical staff for implementation of new programs.
• Ensures safe, effective, efficient implementation of the electronic medical records documentation and ordering.
Budgeting and Financial Management:
• Ensures appropriate coverage for in-house and ICU patients.
• Participates in developing budget for physician departments.
• Works with the chairs, chiefs, and senior leadership team to develop departmental operational goals and facilitates implementation of business, operational, and clinical tactics necessary for growth, improvement, and attainment of hospital clinical, financial, and operational goals.
• Works with chairs to develop goals and holds regular accountability discussions as well as year-end review of performance and achievement.
• Serves as liaison to the Board of Directors, President, senior management team, and medical staff leadership on matters of medical care, medical staff affairs, patient safety, quality, liability risk, and case management.
• Serves as an ex-officio member of all medical staff committees.
• Provides accessibility and effective communication vehicles for the medical staff to ensure its input on key issues such as strategic objectives, leadership and organization, and policy development.
• Supports and participates in system quality and safety initiatives (e.g., weekly system CMO meetings, system collaborative, etc.).
• Participates in Steward Health Care Network (SHCN) local chapter meetings.
• Partners with hospital president and medical staff leadership in recruitment and retention of medical staff.
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
• Commits to recognize and respect cultural diversity for all customers (internal and external) in accordance with the Steward mission and vision statements
• Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
• Performs other duties as assigned
REQUIRED KNOWLEDGE & SKILLS:
• Medical degree with board certification.
• Current licensure or eligibility for licensure in the State of Florida.
• Significant experience in clinical practice.
• Post-graduate training in relevant fields of business or healthcare administration preferred.
• Certified Physician Executive (CPE) certification desirable.
• Prior experience within an acute care community hospital setting.
• Strong clinical competency.
• Contemporary knowledge of laws, regulations, Joint Commission standards, state licensing, and relevant payor requirements relating to medical practice within an acute care hospital setting.
• Knowledge of leading quality measurement, monitoring, and improvement programs, risk management, and utilization review.
• A solid grasp of hospital finance and the ability to effectively participate in strategic planning initiatives, including new program development and clinical services.
• Ability to use objective data to support his/her position and change behavior.
• Ability to act as a strong proponent for clinical quality – inspires others to follow.
• Ability to clearly and effectively communicate new approaches to the medical staff.
• Ability to articulate the clinical quality and regulatory implications of decisions, policies, or actions.
• Ability to command respect, clinically, administratively, and personally.
• Ability to build a collaborative, quality-oriented environment with nursing leadership.
• Ability to interact in a collegial manner with the medical staff, while also being able to effectively articulate his/her point of view.
• Ability to develop a vision for the integration and delivery of medical care and help others move towards and believe in that vision.
I. Education: Medical degree with board certification
II. Experience: Five to seven years of progressive experience in medical staff administrative leadership
III. Certification/Licensure: Licensure or eligibility for licensure in the Commonwealth of Massachusetts