Chief Quality and Medical Officer Hospital Channel

The Chief Quality & Medical Officer Hospital Channel is responsible for ensuring the delivery of exceptional care quality including infection prevention and continuous real-time preparedness and readiness for regulatory and accreditation and certification surveys and system disaster response with the goal of achieving and maintaining substantive compliance with CMS Conditions of Participation and state licensure requirements within the hospital channel. In addition, this officer will work in close collaboration with the System CMO/CNE and each of the hospital leadership teams to deliver clinical differentiation within the hospital channel.  This includes the attainment of service line quality metrics, patient safety performance, risk management mitigation and reliable medical staff credentialing. The direct reports to this position include hospital channel level Senior Directors of Infection Prevention and Regulatory Operations; and the System Infectious Disease Physician Advisor. This position is also responsible for maintaining tight alignment and integration of all joint-venture hospitals within the Texas Health ecosystem regarding quality improvement, management, regulatory/accreditation and licensure activities, and infection prevention.    

Essential Functions:

·         Responsible and accountable for the successful deployment, execution and sustainability of all  relevant system strategies, tactics and action plans in the Hospital Channel, and doing so in accordance with the specifications established by the system’s executive leadership.

·         Responsible for contributing to the achievement systemwide hospital channel key performance indicators (KPIs) and key performance measures (KPMs) related to clinical quality improvement, clinical differentiation and harm reduction.

·         Work collaboratively with the System CMO, CNE, and relevant system leadership to support design and deployment of system service line, patient safety, and risk management initiatives, ensuring that reliable patient safety, risk management and service line measures are appropriately provided and administered within the hospital channel.

·         Ensure highly reliable medical staff credentialing across the hospital channel, including coordination of credentialing reports to QPC and other relevant bodies. Work in close conjunction with system credentialing office to design and deploy standardized and reliable credentialing processes. ,

·         Leads the design and implementation of the Hospital Channel Quality Improvement Plan and serves as the hospital channel representative to  the Quality and Performance Committee (QPC) of the Board. 

·         Responsible and accountable for the design, deployment and ongoing refinement of proactive risk assessments and “early warning systems” to detect material gaps in delivery of exceptional care, with multidisciplinary teams convened to develop and execute appropriate corrective action plans.

·         Responsible and accountable for maintaining regulatory compliance, accreditation and licensure of all assets within the Hospital Channel, including the design and implementation of policies and processes necessary to ensure continuous real-time survey readiness and substantive compliance with all external standards and requirements.

·         Responsible for performance and accountability management of all direct reports based on annual operating plans that set forth clear and measurable goals, priorities, objectives and key results that are tightly aligned with system strategies, tactics, action plans, deliverables and specifications.

·         Responsible for successful alignment and integration of all joint-venture hospitals in the Texas Health ecosystem regarding quality management, accreditation/licensure activities, and infection prevention, through collaboration with the leaders and quality directors et al of each joint venture.

·         Responsible for establishing systematic and highly reliable processes for the identification and sustainable spread of better practices throughout the Hospital Channel; continuously improving the effectiveness, efficiency and productivity of all resources with this role’s span of control and spheres of influence; reducing or eliminating avoidable waste; improving ease of use; and, successfully deploying standardized policies, procedures, practices and processes throughout the Hospital Channel.

·         Serve as a role model of Texas Health’s mission, vision, values, leadership behaviors, Promise standards and Code of Business Ethics; practice servant leadership with a focus on collaboration.