CMO/Chief Medical Officer
Company: Steward Health Care System
Posted on: September 6, 2019
POSITION SUMMARY: The Chief Medical Officer (CMO) reports directly
to the President and CEO of the Hospital 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
Hospital and the community. The CMO is a member of the executive
team of the Hospital, 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 Hospital 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. KEY RESPONSIBILITIES: Quality and Safety, and
Patient Experience of Care:
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.
?? Serves the
Patient Care Assessment Coordinator, accountable for reporting to
the Board of Registration in Medicine.
?? Develops agenda
for Patient Care Assessment Committee of the Board. Regulatory:
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,
BORM, CMS, DPH, DMH, OSHA, FDA, Mass Health, etc.).
?? Is accountable
for completeness of medical record documentation by medical staff.
?? Is accountable
for timely adoption and education related to new policies and
?? Submits timely
SQR reports to BORM; assists in development of annual and
semiannual reports to BORM.
?? Reviews any
reports sent to DPH or DMH prior to submission. Medical Staff
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.
Clinical Quality Committee (Peer Review). Care Coordination and
Actively participates in care management to ensure appropriate
length of stay, appropriate level of care, and minimize preventable
Serves as physician resource on as needed basis for nursing,
leadership, case management, and pharmacy.
participates in the implementation, staff education, and ongoing
evaluation of the electronic health record.
utilization review committee.
?? Participates in
throughput flow improvement work. New Program Development:
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
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
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.
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.
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 Commonwealth of Massachusetts. Significant experience in
training in relevant fields of business or healthcare
Physician Executive (CPE) certification desirable.
?? Prior experience
within an acute care community hospital setting.
?? Strong clinical
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. Skills:
?? 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
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.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER: I. Education:
Medical degree with board certification H. 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 IV.
Keywords: Steward Health Care System, Methuen , CMO/Chief Medical Officer, Other , Methuen, Massachusetts
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