Division CMO

Shift: Day
Schedule: Full - Time Regular
Ardent makes considerable investments in people, technology, facilities, and communities, producing high quality care and extraordinary results. Since 2001, those investments total more than $835 million. From newly constructed facilities and expanded services, to lifesaving technology and outstanding opportunities for employees, Ardent is committed to providing its hospitals and clinics the tools they need to succeed.

The Division Chief Medical Officer (CMO) will interface with Administration, the Medical Staff, and other physician organizations.  The primary objective of this position is to lead clinical and quality initiatives that support consistent clinical performance and quality of care through outcomes measurement and performance improvement processes.

The Division CMO is a leadership position created to build on and strengthen the positive and mutually supportive relationships between hospital administration and the medical staff.  As such, the Division CMO will work closely with the Ardent CMO, administrative staff, members of the medical staff, and its leadership to maintain the high quality of the medical staff and to help lead the medical staff participating in furthering the mission of the organization, with a duty to support the mission and philosophy of  UT Health East Texas.

The Division CMO will work closely with and facilitate positive relationships with nursing leadership in order to ensure successful performance improvement initiatives and overall quality of care.  The incumbent will forge strong linkages and alignments with physician providers.  The Division CMO will support and advise the Medical Executive Committee and the Departments in responding to complaints regarding physician behavior and performance.

Examples of Responsibilities:
• Serve as a member of the senior management team and assist in strategic development of initiatives and programs.
• Investigate and study new developments in medical practice techniques and initiates medical staff and administrative discussions of the implementation of new procedures. 
• Promote effective and timely communication with the medical staff and leadership.
• Participate in the annual operating and capital budget process providing input regarding the budgets of medical affairs and for integrating medical staff and clinical issues in to the Division’s planning, budgeting, and marketing processes.
• Collaborate with key medical staff committees.  Works to forge stronger bonds with the nursing staff.
• Participate in the development and implementation of patient care programs and collaborate with Division and hospital leaders on medical staff partnerships, co-management, and joint ventures.

Medical Staff
• Work to optimize and share best practices as it relates to privileges, bylaws, quality, and medical staff.
• Assist with efforts to identify and retain continuing sources of physician staff and other key employees.  Also, assist in the recruitment and location of physicians and needed specialists for filling hospital staff needs, as needed.
• Receive, investigate, and, where possible, resolve conflicts referred by the medical staff leadership.  Report complaints against members of the medical staff to the appropriate bodies.
• Work with other physician leaders to implement identified best practices and evidence based initiatives.
• Serve as resource for medical staff leaders on complex complaints, incidents and credentialing issues.

Clinical Care Management
• Work with Division and hospital leadership on developing standardized approaches to reducing HACs, Improving Core Measures, and reducing problematic safety events.
• Work with Ardent CMO and Case Management leaders on continuum of care, medical necessity, length of stay, denials, and other key physician driven case management initiatives.
• Evaluate the medical staff quality assurance, disease management and utilization review activities, and develop standards to improve quality outcomes, both clinically and administratively, to ensure the highest standards in the treatment and care of patients, and to ensure compliance with all relevant licensing and accrediting bodies.
• Assist in development, implementation, and evaluation of all care management plans.
• Serve as point person for EPIC clinical resource.
• Develop and implement strategies that control the risks of patient care, monitor the effectiveness of these actions, and ensure proper documentation.
• Dedicate specific resources to patient safety, particularly as related to medications errors and infection surveillance.
• Provide leadership and vision in the development of clinical guidelines and care pathways.
• The CMO will be the Administrative lead to set expectations and drive performance for Hospital Acquired Conditions.
• The CMO will be the Administrative lead for both high reliability and Patient Safety Organization operations within the Division.
• The CMO will be working directly with the Divisional Clinical Informatics team, but it will be the CMO that is ultimately responsible for working with Department Chairs and the Medical Executive Committee to continually improve the Epic system from an “end-user” perspective.
• Lead Pharmacy utilization and cost initiatives by work with both the Pharmacy and Therapeutics committee along with working directly with Department Chairs and individual attendings to ensure a balance between clinical benefits and cost.
• Lead Surgical Supply utilization and cost initiatives by work with both the Supply Chain Management leadership, OR Nursing Directors, Department Chairs and individual attendings to ensure a balance between clinical benefits and cost.

• Provide direction for continuing medical education programs for the medical staff, support staff, graduate, and post-graduate medical education.
• Work with local leadership to ensure appropriate administrative direction for graduate and post-graduate medical education programs

Resource Allocation
• Support the development of managed care plans and physicians services strategic plans supporting the business plan of the organization and develops annual work plans to implement strategies.
• Foster an environment conducive to a managed care market with continuous review of resource utilization, education, and training opportunities that support resource effectiveness.
• Participate in information systems development to allow feedback to physicians regarding practice patterns and performance.
• Support clinical integration and population health initiatives.

Goals & Objectives:
• Become known as a facilitator and champion of new clinical initiatives refining approaches to clinical programs and quality improvement strategies.
• Be recognized as liaison between medical staff leaders and clinicians.
• Provide necessary input in setting organizational performance metrics in care management and in issues relating to regulatory oversight which impact physicians.
• Ensure that Hillcrest HealthCare System excels at delivering the highest quality of care and improve patient satisfaction scores at the hospitals, ensuring the hospitals’ place as the provider of choice for patients.
• Take responsibility for improving clinical quality indicators, patient safety, patient satisfaction and physician satisfaction at the hospital.
• Develop physician leadership where necessary to implement the strategies in specific product lines.
• Develop a deep understanding of the impact of formal Clinical Documentation Improvement programs with reducing the expected rates for Value Based Purchasing metrics. Divisional CMO will work with leadership form HIIM, Coding, Department Chairs, and the Medical Executive Committee to ensure that the Division is maximizing performance in CDI metrics.

The Candidate:
The successful candidate should have a demonstrable track record in physician leadership and experience as a practitioner.  Experience as a hospital medical director and success on administrative side in a complex healthcare environment or equivalent is preferred.   He/she should be knowledgeable about managed care.  He/she will have experience with designing effective clinical practice patterns with physicians to decrease utilization and/or enhance quality of outcomes in service lines. 

The individual will have a demonstrated understanding of general principles of healthcare management, and the complexities of the current financing system.  An understanding of regulatory and accreditation standards and the basic issues and principles of healthcare law and the implications of the Stark Laws, Fraud and Abuse, For-Profit status and physician inurnment and familiarity of medical staff organization, credentialing, bylaws, rules, and regulations.  The selected candidate will have an understanding of principles and implications of standards for quality of care, quality of monitoring, utilization reviews, discharge planning, and related features of today’s healthcare environment. Demonstrated experience in negotiations. The successful candidate will be an acknowledged quality clinician and affirmed as such by peers. 

The competitive candidate may have:
• Demonstrated success with achieving performance goals with Medicare clinical outcomes such as HAIs, PSI90s, and Core Measures.
• Previous leadership experience—and ideally success—with an EMR implementation.
• Leadership of a hospital or system wide patient safety initiative—ERAS, High Reliability interventions, Patient Safety Organization, Peer Review Leadership.
• Leadership in Pharmacy and/or Surgical Supply initiatives. This includes committee work in clinical technology assessments.
• Ideal candidates could be able to demonstrate success in at least three of the above measures, candidates that can also demonstrate experience and success in one or more of the following areas require additional attention:
     Leadership with perioperative throughput
     Service Line development
     Development of an Ambulatory platform via access pints (urgent care, outpatient imaging, ASCs)
     Clinical Informatics
     Telemedicine programs
     Hospitalist or ED Throughput program

• 5-7 years of medical executive leadership roles preferred
• M.D or D.O. Degree required; MBA or other advanced management degree preferred
• Board Certified
• Advanced degree in the area of healthcare administration or related field is desirable


• Clinical and Operational excellence
     Effectively implements evidence-based practice
     Consistently plans, measures, an adjusts performance to ensure optimal outcomes
     Makes Changes that drive increased quality
• Holistic approach
     Diagnoses root causes to problems
     Redirects competing efforts to achieve a greater common good
     Improves how different parts of the organization work together
• Promotes a collaborative environment
     Establishes mutual respect
     Effectively resolves conflict
     Holds oneself and others accountable
• Identifies & Develops Talent
     Recognizes positive performance
     Takes action to address performance shortfalls
     Solicits and acts upon feedback
• Patient Centered Customer Service
     Develops and improves process from a patient perspective
     Actively solicits input to ensure optimal service delivery
     Safeguards and honors other’s dignity and humanity
• Cultivate a compassionate environment
     Cares for the entire person
     Intentionally works put others at ease
     Listens actively to understand and respond to others
• Business Acumen
     Understands how our organization competes and differentiates in the marketplace
     Acts like an owner of the business
     Connects and communicates how individual work contributes to financial objectives
• Continually Simplifies & Improves
     Improves performance by optimizing resources (physical, financial, and human)
     Challenges conventional practices when they are overly complex
     Eliminates waste
• Fosters Innovation
     Seeks out emerging best practices and technologies
     Engages input and involvement from all levels
     Champions adoption of innovation
• Sets Clear Direction
     Defines clear and measurable strategic plans
     Executes to deliver results
     Surveys the relevant environment for trends and opportunities