At Houston Methodist, the Chief Quality Officer (CQO) position is responsible for implementing the HM vision and strategy for excellence in clinical quality outcomes, value, and patient safety. The CQO position collaborates with the System CQO and other system physician leadership in quality and patient safety to support the development of the strategy and goals for leading unparalleled quality and patient safety at HM and development of a High Reliability Organization. This position assures that safe and reliable processes are embedded into the delivery of health care and develops a Just Culture which values patient safety, clinical excellence, evidence-based medicine, and continuous learning. The CQO position works in close association with the System CQO and entity Director and/or VP of Quality & Outcomes and collaborates with all disciplines, hospital leadership, and the medical staff to promote identification of organizational vulnerabilities, health care design using human factors and system principles, and learning to understand and prevent adverse events, achieve high reliable processes, and outstanding clinical outcomes. This position is responsible, along with other members of the HM team, to ensure that HM's unique combination of resources is used wisely to fulfill its responsibilities to its community, to enhance its premier position in the marketplace, and to ensure its continuing leadership in medicine.
This position reports directly to Executive leadership in the organization and has responsibilities which include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.
PEOPLE ESSENTIAL FUNCTIONS- Directs, develops and implements strategic and operational/high level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives.
- Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees.
- Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators.
- Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes.
- Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed.
- Collaborates with physicians and Hospital Leadership in coordinating quality and safety initiatives. Promotes a collaborative environment with directors, physicians, and staff.
- Works with the System CQO and entity CQOs of HM including the Physician Organization to integrate quality programs throughout the HM system and throughout the continuum of care.
- Supports and enforces behavior standards and procedures for medical staff as it relates to factors that contribute to adverse events and quality of care improvement. Provides physician leadership to the quality staff in preparation and review of cases for peer review as needed.
SERVICE ESSENTIAL FUNCTIONS- Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.
- Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department.
- Attends meetings of the Medical Staff to educate and coordinate the activities of the quality and safety program. Participates in orienting Medical Staff and other hospital staff members to policies and procedures related to quality and patient safety.
- Serves as liaison with medical staff to assure appropriate utilization of hospital services/resources and as liaison between physicians and hospital unit employees.
- Communicates with CNO regarding services and clinical enhancements necessary to maintain or achieve a safe, high quality patient care environment. Provides appropriate medical direction in accordance with all applicable hospital policies and procedures.
- Meets with Directors, CNO and CEO on a regular basis to review appropriate data relating to operations, quality of care, and patient safety, and quality of customer service. Assists directors in development and revision to unit specific policies as indicated.
QUALITY/SAFETY ESSENTIAL FUNCTIONS- Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable
- Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety.
- Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).
- Oversees a comprehensive quality and patient safety program; directs the development and implementation of evidence-based practice guidelines. Establishes a just culture, building awareness, implementing policies that support just culture, and building just culture principles into the practices and processes of daily work. Serves as the Physician Champion of Quality and Safety and incorporates the Medical Staff Leadership into the Program.
- Develops long-range goals, annual objectives, and strategies for the Hospital, Quality and Patient Safety Program incorporating all aspects of Performance Improvement, Risk Management, Environmental Safety, and Infection Control. Develops high reliability and manages reliability in the order of System (to become effective and resilient), Human, (both human performance and human behavior), and Organization (achieve sustainment and become predictive). Actively participates in the recruitment of medical staff to meet long term objectives.
- Assures compliance with the regulatory agencies in the design and execution of the program and with hospital and other regulatory safety requirements. Participates in accreditation and other surveys as appropriate.
- Oversees investigation and internal reporting of sentinel events and serves as physician champion in PI efforts related to Patient Safety. Serves as the primary investigator for Medical Staff interviews for sentinel events and other medical care questions.
- Collaborates in the governance over development of physician order entry, bar coding, clinical decision support, safe medication delivery, and other devices in the delivery of clinical care.
FINANCE ESSENTIAL FUNCTIONS- Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness.
- Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications.
- Supports and implements a Quality and Patient Safety strategy that links delivery of clinical care with education and research, adopting management and operations processes that maximize function and minimize administrative overhead.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS- Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings.
- Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate.
- Ensures own career discussions occur with appropriate management. Completes and updates My Development Plan (MDP) on an on-going basis. Conducts conversations with staff on their development and MDP.
- Works with HM Information Technology (IT) staff, Quality staff and researchers, and medical staff members to develop IT strategies that will support patient care quality and quality research. Supports the implementation of information technology to deliver added value, and assure that implementation is accomplished for patient safety, excellent outcomes, and for acceptance by both professional and support staff.
- Develops and delivers educational and training programs for all clinical faculty and staff, as well as management and Board members.
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION- Doctorate degree in medicine
WORK EXPERIENCE- Previous experience as quality executive preferred
- Experience in academic medicine preferred for entities with academic training programs
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