CMO, Chief Medical Officer Good Samaritan

Department:

10010 Advocate Good Samaritan Hospital -

Administration Status:

Full time

Benefits Eligible:

Yes Hours Per Week:

40

Schedule Details/Additional Information:

This is an on-site, in-person role at Good Samaritan Hospital. Pay Range $151.65 - $242.65 The Medical Management leadership purpose is to continue and further develop positive, mutually supportive relationships between hospital administration, the medical staff, and Advocate Health Care. The Vice President of Medical Management works closely with administrative staff, members of the medical staff and its leadership, and Advocate leadership to improve the quality of the medical staff and to engage the medical staff in furthering the mission of Advocate Health Care. This position also includes accountability to physician recruitment, physician relations, and network development. The Quality leadership purpose is to develop and direct an organization-wide culture around quality improvement, patient, associate and volunteer safety, risk management and regulatory compliance. This position directs the areas of: Quality Improvement, Patient Safety and Infection Control and Risk Management. This position also provides oversight for The Joint Commission accreditation process and compliance with all other regulatory agencies.

Major Responsibilities:

Quality Improvement:

Direct the activities of the following functions: Quality Improvement, Safety and Infection Control and Risk Management to ensure quality of care, appropriate resource utilization, patient safety, patient satisfaction and compliance with local, state and federal regulations. Responsible for the development and implementation of the Quality and Patient Safety Plan and Infection Control Plan for the organization. Recruit, select, mentor, and evaluate HSL performance of direct reports. Implement corrective action and motivate direct reports to achieve hospital, departmental and personal goals and objectives. Direct managers to ensure the effective utilization of human resources. Appropriately manages budgeted vs. actual FTEs, open requisitions and profile processing, performance reviews within policy guidelines. Develop annual operating budgets (revenue, expense, activity and FTEs) Develop capital budgets (maintenance and strategic capital). Monitor budgets, investigates, and reports on any reasons for variances. Ensures that all departmental expenses are processed appropriately, timely and according to Advocate's financial control policy and corporate compliance guidelines. Provide leadership and oversight to department chairs and medical directors in matters related to medical staff quality improvement, risk management and utilization review activities. Develops standards to improve quality outcomes, both clinically and administratively, to ensure the highest standards in the treatment and care of patients, and to ensure compliance with the hospital's goals and objectives and all relevant licensing and accrediting bodies. Develop and implements strategies to control the risks of patient care, monitors the effectiveness of these actions, and ensures proper documentation. Serve as a member of the "core team" as necessary to identify and address sentinel events. Participates in the root cause analysis process for events related to the medical care of patients. Supports physicians with disclosure of medical errors when appropriate. Lead and participate on hospital clinical improvement teams as needed, including providing leadership and vision in the development of clinical guidelines and care pathways. Provide input into the direction of the medical records department and ensures that such medical records, medical information, and charting systems are administered in an orderly and systematic manner and accurately reflect the data upon which treatment is based and the actual treatment provided. Support and provide leadership regarding all Advocate quality and care management initiatives. Medical Staff Establishes priorities and directs the staff and activities of the Medical Staff Office including providing support for medical staff governance. This support includes involvement in and oversight responsibilities for physician services, credentialing, bylaws, orientation of new physicians, medical staff committees, and providing the medical staff chairmen with intervention assistance in medical staff counseling and discipline. Advises all medical departments regarding appointment and the delineation of clinical privileges, OPPE/FPPE and other credentialing and quality of care concerns. Works with medical staff to assure compliance with medical staff bylaws, rules and regulations, policies and procedures and regulatory requirements. In concert with the President of Medical Staff, receives, investigates, and where possible, resolves conflicts referred by the medical staff, and reports complaints against members of the medical staff to the appropriate bodies. Provides direction and leadership in dealing with specific physician-system integration issues including, but not limited to: partnering with physicians, physician involvement in governance, physician management and leadership development, medical staff relations problems, physician business relationships with hospital/network, physician practice acquisition, development of cost effectiveness plans, development of continuous performance improvement plans, promotion of physician teamwork, promotion of a level playing field for physicians and promotion of increasing patient value through successful integration. Regulatory Compliance Ensure organizational regulatory compliance including: The Joint Commission (TJC), the Illinois Department of Public Health, the Centers for Medicare and Medicaid, OSHA, CDC, etc. Direct TJC and IDPH activities including: acting in the role of liaison for onsite surveys, investigation and resolution of patient complaints, submission of publically reported data. Ensure implementation of and compliance with the National Patient Safety Goals, Leapfrog safety initiatives, IHI safety projects, CMS Conditions of Participation, etc. Maintains an expert knowledge of TJC standards and guidelines, as well as clinical standards for federal programs and state licensure requirements, including proposed changes. Patient Safety Create and sustain a culture of patient, associate, physician, volunteer and visitor safety across the organization. Direct safety initiatives across all departments. Establish and participate in a robust causal analysis process to support the prevention of future errors within the organization. Responsible for the administration of the annual Culture of Safety Survey, providing executive summary results and developing organizational action plans to address identified gaps. Ensure infection control practices for hand hygiene, isolation compliance, emergency preparedness, etc. are in place and effective in providing patient and associate safety. Responsible for an effective event report tracking process to identify and address individual, departmental and system issues that may contribute adversely to patient safety. Administrative Participates as a member of the hospital's Executive Team and the Advocate Medical Management Team. Network Assists hospital efforts to identify and retain physician staff and other key employees. Also, assists in the recruitment and location of physicians and needed specialists for filling hospital staff needs. Advises the Chief Executive Officer of the hospital and APP in the development and implementation of joint ventures, physician practice acquisitions and mergers. Assists in evaluating the medical practice of future acquisitions and recommends appropriate changes and enhancements to practice operations. Assists in developing inter-hospital referral programs and/or relationships along strategic business lines. Clinical Reviews the delivery of services and care provided to patients for medical necessity, appropriateness, and conformance to professional standards as determined by the appropriate medical staff committees. Education Provides direction for continuing medical education programs for the medical and support staff. Provides direction for physician management and leadership education; participates fully in educational programs. Managed Care Participates in development of managed care and physician services strategic plans supporting the business plan of the organization and develops annual work plans to implement strategies in conjunction with Advocate managed care programs. Monitors risk contracts, assists physicians in understanding their performance and takes corrective action when necessary. Fosters an environment conducive to a managed care philosophy with continuous review of resources utilization, education, and training opportunities that support managed care effectiveness. Sponsors and facilitates APP, Hospital and Medical Staff integration. Information Systems Participates in information systems development to engage physicians regarding practice patterns, performance and resource utilization, particularly in support of care management activities. Assures proper analysis of data occurs to identify patterns and trends, and reports the ongoing result of quality review to medical staff departments and individual members. Executive Representation Serve as the executive representative for system, hospital and community committees providing leadership and support as needed. Provide executive leadership for the Clinical Excellence Committee of the Governing Council, responsible for agenda preparation, meeting facilitation and report summary to Governing Council. Serve as the executive sponsor for the Patient Safety Steering Committee, the Hand Hygiene Steering Committee, the Infection Control Committee, The Accrediting Organization Leadership Committee, and the PI Showcase. Serves as the executive representative as requested on community boards. Champion, sponsor, communicate and oversee the implementation of system-wide care initiatives in conjunction with the site Chief Executive and CNE. Develop and deploy a systematic approach to performance excellence and process improvement by creating a culture of continuous improvement throughout the entire organization. Direct the Medical Staff Quality Peer Review Committee process in collaboration with physician leaders for the following

Committees:

Blood and Blood Products, all Medical Staff Department Clinical Quality councils (Surgery, Medicine, Family Practice, Cardiology/Cardiovascular Services, Obstetrics/Gynecology, Pediatrics, Psychiatry, Anesthesia, and Emergency Department, Trauma, Pharmacy and Therapeutics Committee, Infection Control Committee, Intensive Care Committee, and Endoscopy Committee). Provide hospital executive presence on the physician Clinical Practice Improvement Committee (CPIC). Provide executive leadership for Quality Improvement initiatives including collaboratives with the Institute for Healthcare Improvement, The Accrediting Organization and the Illinois Hospital Association. Develop and deploy organizational training for hospital executives, department directors and managers as well as front line staff in improvement methodologies, the use of quality tools, the effective use of data for decision-making and indicator development. Provide executive leadership for PI Showcase, clinical quality improvement teams, root cause analysis teams and rapid improvement event teams. Participate, as requested, in investigating and responding to patient complaints regarding the medical staff and quality of care/service.

Licensure:

Physician Education/Experience Required:

MD. Minimum 5 years clinical experience. Minimum 8 years management experience. Preferred formal management education. Demonstrated continuous education in management and leadership development. Experience with financial and clinical risk management. Experience with and commitment to Accrediting Organization and NCQA performance improvement expectations for health care organizations; familiarity with HEDIS 3 indicators for quality. Experience with physician education design and implementation. Experience with and commitment to continuous performance and quality improvement methodology. (Identify, collaborate, understand, improve, mentor, assess). Familiar with Lean tools.

Knowledge, Skills & Abilities Required:

Computer knowledge. Knowledge of IS/SI criteria, discharge planning. Working knowledge of Case Management and Quality Management. Written and verbal communication skills required. Total commitment to customer service; (identified customers are physician community, patient community, payers of health care services, Advocate associates). Inherent identification with Advocate values. Understanding of emotional intelligence. Illinois License. Board Certification. Medical Staff Membership (Advocate).

Physical Requirements and Working Conditions:

Candidate must be willing to attend, onsite and offsite, department meetings and educational activities. Must be able to perform basic administrative director functions, participation in outside professional activities and maintain proficiency in the department's software computer programs. The candidate must also be able to perform various physical tasks with a high degree of proficiency, such as articulating, hearing, and viewing and walking throughout the hospital. The candidate must be available on a 24-hour basis and able to travel to corporate and community functions as appropriate. (must develop measurement tools). This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Our Commitment to

You:

Advocate Health offers a comprehensive suite of

Total Rewards:

benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs

Educational Assistance Program Note:

Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview. About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient's experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It's offering more sites of care than any other health system in the Midwest. But there's a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we'll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care