Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Reporting to the Chief Physician Executive Officer (CPEO), the System Chief Medical and Quality Officer (CMQO) is a physician executive  accountable for all aspects of providing high quality and safe care across the CommonSpirit Health ministry, resulting in measurably improved outcomes for patients. Examples include inpatient, ambulatory, and across continuum of care including but not limited to ACS, Home Care, Senior Living  and other clinical models. Additionally, this position will be responsible for ensuring that credentialing, privileging and peer review serve to protect patients across the system, meet regulatory requirements and promote excellence in clinical quality, safety, and patient-centeredness.

The CMQO is a strategic thinker, a visionary, an innovator, a change agent, an effective public speaker, an educator and an influencer. This position provides leadership, direction and guidance in the areas of Quality Management, Infection Prevention, Patient Safety, Clinical Risk Management, and Medical Staff Services/Credentialing, Regulatory and & Accreditation, Populations Health, and related functions. The CMQO embodies a collaborative and optimistic style needed to deliver results and strategically build teams across multiple geographies. The successful candidate will lead a clinical team of direct reports including but not limited to Inpatient and Ambulatory Quality Leadership, Clinical Standards and Variation Reduction Leadership and will also provide leadership to our regional and market-based Chief Medical Officers including work across the ministry and connect with other executives especially our nursing leaders to provide a dyad model of leadership and drive quality and safety outcomes.

Responsibilities
Strategic LeadershipLead and facilitate the development of the CommonSpirit’s strategic plan for quality and safety together with key stakeholders, formal and informal physician leaders, nursing, executives, physician enterprise, and employees with management responsibilities for quality, safety and performance improvement. Creates and implements a consistent enterprise wide quality vision with specific strategies as needed within the continuum of care.Develop an annual quality performance plan, goals and priorities for CommonSpirit Health to be approved by CPEO, CEO and Board of Stewardship Trustees (BOST). Support health equity efforts to provide equitable access and outcomes to all patients.Develop metrics to guide our efforts in quality, safety, and patient satisfaction and oversee the development of performance improvement plans to guide improvements in each of these areas; developing a system-wide, full continuum performance improvement program. 

Regulatory Compliance and Accreditation

Responsible for ensuring that credentialing, privileging and peer review serve to protect patients across the system, meet regulatory requirements and promote excellence in clinical quality, safety, and patient-centeredness. The CMQO will seek to centralize and standardize policies, procedures, and processes wherever feasible and desirable.Contributes to the development of the system’s strategic goals in relation to quality/safety initiatives and the reduction of variation in care.

Quality Metrics and Reporting

Identify those quality and safety metrics that are tied to public reporting and/or reimbursement and that are critical to establishing a national leadership position in quality and safety. Create a quality performance dashboard for internal stakeholders that will allow us to measure our progress against the annual quality goals
Support the development and implementation/communication of a standardized, system-wide quality performance reporting process. Create meaningful quality and safety performance reports for internal and external stakeholders that will demonstrate our results and progress against the quality performance plan. Identify and incorporate appropriate benchmarks for comparative quality reporting. Communicate the quality results and opportunities for improvement to physicians. Work with the Service Lines and appropriate stakeholders/internal partners to develop quality goals and metrics. Liaison with CFO and CIO regarding data capture and reporting that will support quality measurement, cost of care and high reliability.Ensures on-going outcomes measurement trending is maintained and assessed to identify priorities and opportunities for improvement; continuously generates ideas for improvement. 

Innovation

Identify and implement innovative solutions to gaps in quality, patient safety, and cost of care. Implement a standard improvement methodology and process improvement methodologies to accelerate performance improvement and standardize improvements throughout the System. Develop a process for participation in quality pilot/demonstration projects and for measurement and reporting of successes and failures in these projects. Collaborate with the CIO, CFO, COO, CNOs, Service Line leaders, and Physician Enterprise to develop new processes and review new technologies that promote patient-centered, effective, and evidence-based practices that will promote excellence in quality and patient safety. Support Service Line leadership to identify and then rapidly deploy and standardize best practices across the system. Assist the CIO in the development, integration and adoption of evidence-based and consensus-driven protocols for information management and decision-support.

Leadership

Persuasive speaker and listener who uses data to drive performance improvement. High visibility with physicians and APPS throughout the CommonSpirit Health System. Network with quality leaders across the country in order to continue to generate new ideas. Grow and develop current and future physician leaders through mentoring and coaching. Engage patient care providers with varying roles, including physicians, nurse practitioners, physician assistants, nursing staff, and other health care professionals, to contribute to the quality and safety initiatives of the Health System.

Qualifications
Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).

Licensure and Certifications:  Current Clinical Professional License required and board certification in their respective speciality. 

Experience:  Minimum of twelve (12) years clinical experience and at least seven (7) years leadership experience managing quality, patient safety and related key initiatives in a large, complex integrated health system or similarly complex environment.  Preferred Experience: Demonstrated track record of success leading Quality and Safety program, with accountability to CMO, CEO and Board of Trustees. Successful leadership and supervisory experience within a large, complex, integrated healthcare system required. Demonstrated proficiency in oral/written communication, including presentation to executive level audience and physician leaders.

Benefits include Medical, Dental, Vision, Paid Time Off, Holidays, Retirement Program, Disability Plans, Tuition Reimbursement, Adoption Assistance, Employee Assistance Program (EAP), Discount Programs, Life Insurance Plans, Worker Compensation, Dress for Your Day Policy, Voluntary Benefits. Position is eligible for incentive pay based on company performance. 

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