Description
Actively leads activities, processes and policies that result in high quality patient care driven by system-wide clinical practices and standards. Acts as management resource for the hospital and collaborates with the entire hospital leadership team to facilitate a comprehensive and systematic approach to medical practice issues and standards within the context of hospital priorities, environmental factors, and industry trends.
Reports directly to the President/CEO and is a member of the senior leadership team. Leads the medical staff and the leadership of the hospital (San Juan Regional Medical Center – SJRMC) and the employed medical group (San Juan Health Partners – SJHP) in fulfilling their responsibilities to patients for the provision of quality care. The position regularly attends senior leadership, Board of Directors, and medical staff meetings. Works with the medical staff to ensure the effective and efficient delivery of high-quality medical care, ensuring operational and service excellence and best practices throughout the hospital. Assists in matters pertaining to regulations, accrediting, safety, physician recruitment and retention, clinical informatics, quality systems and compliance. Collaborates with the medical staff on appropriate documentation and coding of medical records and facilitates standardization of care and processes across the hospital and employed medical group.
Requirements
Required Behaviors:
As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications:
MD or DO degree
Licensed in the State of New Mexico
Knowledgeable in quality systems and processes
Knowledgeable in CMS Value Based Purchasing Program, CMS 5-star Rating Program and other publicly reported quality sources
Have demonstrable experience in leading improvement in medical staff and hospital overall quality and patient safety outcomes
Build consensus among all segments of the medical staff and SJRMC/SJHP leaders around key strategies and tactics needed to drive excellence in overall quality and patient safety outcomes
Be a champion of evidence-based standards of care and lead elimination of non-value-added variation
Knowledgeable of medical staff credentialing processes and standards
Clearly articulate and support the role information technology plays in the delivery of quality healthcare
Possess well-honed leadership and administrative skills to inspire respect from peers and staff, such as:
Strong problem-solving
Excellent communication with personnel, medical staff, and members of community
Conflict resolution
Strategic planning
Decision-making using independent judgement
Attention to detail, strong organizational skills, and ability to discern which issues warrant CMO oversight vs. delegation to team
Stress management and professional composure in high pressure situations
Manage multiple and varying high-priority objectives and deadlines to successful completion
Committed to the organization’s mission and values and service standards
Minimum of five (5) years of post-residency experience in direct patient care in a hospital setting
Minimum of three (3) years experience in a supervisory position, managing direct reports in a hospital setting
Preferred Qualifications:
Proven business management experience and/or formal education (e.g., MBA)
Duties and Responsibilities:
Supervises Medical Staff Services
Works closely with medical staff leadership to ensure compliance with initial credentialing, reappointment, bylaws, rules, peer review, corrective actions and other matters impacting quality and patient safety
Oversees hospital-based Medical Directors to improve the overall quality and efficiency of patient care and ensure their work is strategically relevant and promotes the Mission, Vision, and Values
Serves as dyad Physician partner to SJHP Chief Administrative Officer, supporting all Medical Directors, co-leading SJHP provider and executive committee meetings, engaging routinely with employed provider groups, and providing support in situations where no Medical Director is in place
Drives open communication and dyad partnerships between Medical Directors and nursing floor managers through effective 1:1’s, clear goals, and follow-up to established due dates
Establishes and maintains well-constructed framework to provide frequent and ongoing touchpoints (e.g., rounding visits, skip-level discussions, employee forums, etc.) with frontline staff to ensure clear awareness of clinical care practices within SJRMC and SJHP
Works with CEO to monitor Bylaws and other governing documents of medical staff to verify that they are current, consistent, and comply with internal processes and outside regulations
Works with Quality Systems and Utilization Management to facilitate physician participation in quality and utilization initiatives
Serves as member of Medical Staff Quality Improvement & Peer Review Committee
Works closely with leadership to ensure compliance with medical staff and patient care related to DNV, CMS, and other regulatory requirements
Acts as liaison between medical staff and administration concerning practice of medicine, strategic development, collaboration, collegiality and fairness
Collaborates with Chief of Staff and other medical staff leadership on physician matters and facilitates resolution of physician concerns and conflicts
Provides clinical guidance for Quality Systems and ensures that quality programs are developed and implemented in clinical areas, including disease management programs, clinical protocols and guidelines, and reviews outcomes of these programs
Assists the Section Leaders with review of Quality Metrics
Works closely with General Counsel to ensure medical staff compliance with State and Federal laws, applicable licensure, accreditation and regulatory bodies, and to plan, coordinate and evaluate related risk management activities
Responsible for budget development, implementation, monitoring and accountability for areas reporting to the CMO
Attends Board meetings and serves as the primary administrative representative to the Board for issues concerning medical staff quality, and makes periodic board reports regarding patient care, quality and related activities and initiatives
Attends section, department, hospital clinic, employed medical group, and community meetings as requested to update members of the medical staff regarding hospital issues and address concerns
Provides advice to management team and physicians on clinical issues pertaining to resource utilization, utilization review, quality improvement, risk management, clinical equipment and other issues as appropriate
Ensures appropriate processes and accountability for receiving and resolving patient and family complaints related to medical care
Creates strong partnership with other senior managers to closely align goals and become an innovative healthcare system leading the nation in quality and safety
Continues transformation to electronic medical records with emphasis on continuous quality improvement and patient safety initiatives
Establishes known and visible presence in the organization and develops reputation for being accessible and approachable
Develops strategy and implement processes for improvement of quality standards
Maintains and enhances the hospital’s traditionally strong relationships with physicians based at SJRMC, SJHP, and within the community and continues to create a sense of excitement about the future for the SJRMC and SJHP to be the premiere destination for patient care
Models leadership standards for the service provided through personal behavior
Demonstrates commitment to the hospital and employed medical groups through availability and flexibility
Participates in local, state and national professional organizations as necessary
Actively engages in targeted clinical responsibilities (i.e., a few days a month) to maintain skills, enhance credibility with physicians and APPs, and ensure ongoing alignment with SJRMC/SJHP patient care practices
Pursues formal and informal continuing education in healthcare, administration, management, etc., to maintain, strengthen and broaden concepts, philosophy and ability
Each employee is responsible for implementing SJRMC’s Service Standards into their daily work:
Safety, Courtesy, Effectiveness, and Stewardship
Performs other duties as assigned
Physical Demands and Environmental Work Conditions:
Fast paced environment
High levels of activity with many interruptions
Work outside normal office hours
Minimal lifting
Sitting for extended periods of time
