Description

Actively leads activities, processes and policies that result in high quality patient care driven by system-wide clinical practices and standards. Acts as a management resource for the hospital and collaborates with the entire hospital leadership team to facilitate a comprehensive and systematic approach to medical practice issues and standards within the context of hospital priorities, environmental factors, and industry trends.

Reports directly to the President/CEO and is a member of the senior leadership team. Leads the medical staff and the leadership of the hospital (San Juan Regional Medical Center – SJRMC) and the employed medical group (San Juan Health Partners – SJHP) in fulfilling their responsibilities to patients for the provision of quality care. The position regularly attends senior leadership, Board of Directors, and medical staff meetings. Works with the medical staff to ensure the effective and efficient delivery of high-quality medical care, ensuring operational and service excellence and best practices throughout the hospital. Assists in matters pertaining to regulations, accrediting, safety, physician recruitment and retention, clinical informatics, quality systems and compliance. Collaborates with the medical staff on appropriate documentation and coding of medical records and facilitates standardization of care and processes across the hospital and employed medical group.

Duties and Responsibilities:

• Supervises Medical Staff Services
• Works closely with medical staff leadership to ensure compliance with initial credentialing, reappointment, bylaws, rules, peer review, corrective actions and other matters impacting quality and patient safety
• Oversees hospital-based Medical Directors to improve the overall quality and efficiency of patient care and ensure their work is strategically relevant and promotes the Mission, Vision, and Values
• Serves as dyad Physician partner to SJHP Chief Administrative Officer, supporting all Medical Directors, co-leading SJHP provider and executive committee meetings, engaging routinely with employed provider groups, and providing support in situations where no Medical Director is in place
• Drives open communication and dyad partnerships between Medical Directors and nursing floor managers through effective 1:1’s, clear goals, and follow-up to established due dates
• Establishes and maintains well-constructed framework to provide frequent and ongoing touchpoints (e.g., rounding visits, skip-level discussions, employee forums, etc.) with frontline staff to ensure clear awareness of clinical care practices within SJRMC and SJHP
• Works with CEO to monitor Bylaws and other governing documents of medical staff to verify that they are current, consistent, and comply with internal processes and outside regulations
• Works with Quality Systems and Utilization Management to facilitate physician participation in quality and utilization initiatives
• Serves as member of Medical Staff Quality Improvement & Peer Review Committee
• Works closely with leadership to ensure compliance with medical staff and patient care related to DNV, CMS, and other regulatory requirements
• Acts as liaison between medical staff and administration concerning practice of medicine, strategic development, collaboration, collegiality and fairness
• Collaborates with Chief of Staff and other medical staff leadership on physician matters and facilitates resolution of physician concerns and conflicts
• Provides clinical guidance for Quality Systems and ensures that quality programs are developed and implemented in clinical areas, including disease management programs, clinical protocols and guidelines, and reviews outcomes of these programs
• Assists the Section Leaders with review of Quality Metrics
• Works closely with General Counsel to ensure medical staff compliance with State and Federal laws, applicable licensure, accreditation and regulatory bodies, and to plan, coordinate and evaluate related risk management activities
• Responsible for budget development, implementation, monitoring and accountability for areas reporting to the CMO
• Attends Board meetings and serves as the primary administrative representative to the Board for issues concerning medical staff quality, and makes periodic board reports regarding patient care, quality and related activities and initiatives
• Attends section, department, hospital clinic, employed medical group, and community meetings as requested to update members of the medical staff regarding hospital issues and address concerns
• Provides advice to management team and physicians on clinical issues pertaining to resource utilization, utilization review, quality improvement, risk management, clinical equipment and other issues as appropriate
• Ensures appropriate processes and accountability for receiving and resolving patient and family complaints related to medical care
• Creates strong partnership with other senior managers to closely align goals and become an innovative healthcare system leading the nation in quality and safety
• Continues transformation to electronic medical records with emphasis on continuous quality improvement and patient safety initiatives
• Establishes known and visible presence in the organization and develops reputation for being accessible and approachable
• Develops strategy and implement processes for improvement of quality standards
• Maintains and enhances the hospital’s traditionally strong relationships with physicians based at SJRMC, SJHP, and within the community and continues to create a sense of excitement about the future for the SJRMC and SJHP to be the premiere destination for patient care
• Models leadership standards for the service provided through personal behavior
• Demonstrates commitment to the hospital and employed medical groups through availability and flexibility
• Participates in local, state and national professional organizations as necessary
• Actively engages in targeted clinical responsibilities (i.e., a few days a month) to maintain skills, enhance credibility with physicians and APPs, and ensure ongoing alignment with SJRMC/SJHP patient care practices
• Pursues formal and informal continuing education in healthcare, administration, management, etc., to maintain, strengthen and broaden concepts, philosophy and ability
• Each employee is responsible for implementing SJRMC’s Service Standards into their daily work:
                                                       Safety, Courtesy, Effectiveness, and Stewardship

Requirements

Required Behaviors:

As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications:

• MD or DO degree
• Licensed in the State of New Mexico
• Knowledgeable in quality systems and processes
• Knowledgeable in CMS Value-Based Purchasing Program, CMS 5-star Rating Program and other publicly reported quality sources
• Have demonstrable experience in leading improvement in medical staff and hospital overall quality and patient safety outcomes
• Build consensus among all segments of the medical staff and SJRMC/SJHP leaders around key strategies and tactics needed to drive excellence in overall quality and patient safety outcomes
• Be a champion of evidence-based standards of care and lead elimination of non-value-added variation
• Knowledgeable of medical staff credentialing processes and standards
• Clearly articulate and support the role information technology plays in the delivery of quality healthcare
• Possess well-honed leadership and administrative skills to inspire respect from peers and staff, such as:
• Strong problem-solving
• Excellent communication with personnel, medical staff, and members of the community
• Conflict resolution
• Strategic planning
• Decision-making using independent judgement
• Attention to detail, strong organizational skills, and ability to discern which issues warrant CMO oversight vs. delegation to team
• Stress management and professional composure in high-pressure situations
• Manage multiple and varying high-priority objectives and deadlines to successful completion
• Committed to the organization’s mission and values and service standards
• Minimum of five (5) years of post-residency experience in direct patient care in a hospital setting
• Minimum of three (3) years of experience in a supervisory position, managing direct reports in a hospital setting

Preferred Qualifications:

• Proven business management experience and/or formal education (e.g., MBA)