Job Description
Key Responsibilities of the role
Corresponding Key Activities performed by the role
LEADERSHIP
Leads the organization’s clinical staff and serves as a role model for professional excellence
Leads in the development, approval, authorization and implementation of agreed clinical policies and procedures
Assumes responsibility for establishing a clear system of communication with the medical workforce throughout the organization
Attends all relevant corporate meetings and meets regularly with the Department Heads
Fosters relationships with fellow medical leaders, academics and clinicians, and supports Department Head and Division Chiefs in championing the collaboration of research and exchange of ideas for best practice, helping to build the organization’s reputation for clinical excellence
Delegate’s responsibilities to the Deputy Chief Medical Officer and other members of staff as required.
Assumes additional administrative duties as requested by the Corporate Team
QUALITY AND PATIENT SAFTEY
Accountable to ensure the highest standards for clinical quality and patient safety.
Responsible to monitor, expand and improve outpatient and inpatient clinical care and service within the BE and collaboratively across the Health System.
Supervise with the Chief Quality Officer and/or Director of Quality and the Quality Department to develop and implement annual quality and patient safety plan for the BE which is reviewed and approved by the Corporate Clinical Quality Department including a plan for the development and monitoring of key quality and safety benchmarked indicators.
Support the BE Quality and Patient Safety Sub-Committee.
Oversee the BEl Peer Review Committee (s).
Oversees the Chairs and Chiefs performing regular evaluations on each Medical Staff Member based on the Physician Pay for Performance Program (PPFP) and OPPE (Ongoing Professional Practice Evaluation) and FPPE (Focused Professional Practice Evaluation) criteria set forth by Corporate Clinical Affairs and recommend and follow-up on appropriate action.
Evaluate and take appropriate action on medical staff members as incidents arise.
Ensure development and implementation of evidence based clinical practice guidelines in prioritized high risk clinical areas
Review and approve appropriate Departmental Credentialing and Privileging criteria. Develop and implement additional privileging criteria as new procedures or programs are requested and obtain approval of the Credentialing Committee.
Review and take action on all Medical Staff members requesting Medical Staff privileges
Review, trend and report safety events. Implement action steps to prevent future events.
Ensure Departmental compliance with Joint Commission International, HAAD,FANQ and other regulatory and compliance agencies.
Participate in BE and Health System Quality and Safety meetings as requested.
Review and take actions on all sentinel events and PSN reported incidents
OPERATIONAL EXCELLENCE
Development and implementation of strategies to facilitate the delivery of care and service excellence for physicians, staff and patients.
Review periodic patient satisfaction for the BE and implement improvement actions when appropriate.
Review periodic Patient Satisfaction for members of the medical staff and implement improvement actions as appropriate, including clarifying and enforcing the role of the physician in the patient experience.
Support BE initiatives to improve the operational processes that impact physicians and patients.
Jointly with the BE, develop, implement, monitor and report annual operational performance goals.
Attend meetings that address performance improvement relative to service provided to patients.
Review and take action on quarterly targets and indicators
Oversees, guides, supports and ensures performance of the Transition of Care Case Management program and systems within the BE. Coordinates and collaborates in the work of the Case Manager with a focus on appropriateness and efficiency of admissions, continued stay consultations, treatment, care and throughput, as well as effective and timely discharge and post- acute placement.
GROWTH
Responsible to promote growth in clinical services across the system through the development of integrated clinical programs, robust educational programs and a strong research presence.
In conjunction with the BE and Service Line leaders, conduct annual market share and the competitive analyses for each major program.
In conjunction with the hospital and Service Line leaders, develop an annual strategic plan to identify potential areas for programmatic growth at the System level and for each hospital. If approved, the CMO will support implementation of the new program.
Identify the clinical capital needs including IT support of the BE to support the Service Lines at the BE.
Support strategies for system-wide clinical integration and clinical effectiveness in collaboration with corporate and divisional leadership.
Facilitate and participate in fund development activities in the areas of promotion of extramurally funded research, the organization and delivery of clinical services, the generation of gifts and endowments, the creation and licensing of intellectual property and the negotiation of contracts for clinical research and other services.
PEOPLE
In collaboration with the HR Department, responsible to recruit and retain superior and diverse faculty with strong track records in clinical care, education and/or research in specific areas targeted for growth and development.
Evaluate Department Chiefs annually based on agreed upon goals in all six Pillars of Excellence.
Recruit and implement programs for retention of Medical Staff members based on the programmatic needs of the BE.
Assigns clinical, administrative, research and education FTE to each physician at least on an annual basis and ensures that the Oracle Database is maintained to include FTE information as well as assigned standardized Department/Section, Tier and licensure.
Develop succession plan and mentor potential candidates for senior positions
In conjunction with the BE, recruit support personal necessary to support programmatic growth and patient /physician/employee satisfaction
FINANCIAL PERFORMANCE
Responsible to promote system-wide performance standards for clinical services to optimize financial and operational performance.
Accountable for overall financial performance of the employed physicians.
Oversee the implementation and effectiveness of BE Utilization Management (UM) Plans and Committees. Assume or assign medical staff leadership and participation in the UM Committee
Evaluate the monthly productivity and financial performance including but not limited to length of stay, readmission within 30 days, and cost per patient day of the employed Medical Staff members. Institute action steps to improve performance when necessary.
In conjunction with the BE administrative staff, develop an annual operational and capital budget.
Support the Service Line Councils, Clinical Support Integration Councils, and Centers of Excellence Program.
Support supply chain initiatives.
Jointly with the BEl, develop, implement, monitor and report annual financial goals for the BE. Create and implement action plans for improvement when appropriate.
EDUCATION AND RESEARCH
Responsible to support and develop an integrated strategy for undergraduate, graduate and continuing medical education consistent with the priorities and standards endorsed by the ACGME .
Oversee the medical student, residency and fellowship programs for the BE and ensure they are in compliance with all pertinent agencies.
Ensure BE support for Medical Student education and instruction including but not limited to teaching related activities, committees, career advising and mentoring.
Ensure and support CME for the BE.
Oversee research IRB compliance for the BE.
Support academic and scholarly pursuits such as papers and presentations that promote the academic mission.
Mentor and develop faculty and to promote excellence in teaching and scholarly activity.
Support and develop an integrated strategy for faculty participation in basic, translational or clinical research.
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