Ambulatory Chief Quality Officer

Prestige Staffing is hiring for an AmbulatoryChief Quality Officer to provides oversight, development and administration of local OU entity quality management, performance improvement, and regulatory compliance activities, to achieve the systems goal of clinical excellence. Supports the EHC Chief Quality Officer and Office of Quality leadership team with development and implementation of quality improvement activities. Serves as the OU entity QPS lead of oversight of infection control & prevention, patient safety, performance Improvement/process improvement and clinical innovation Oversees physician peer review and professional performance evaluationsPrimary Duties and Responsibilities:Collaborates with the CQO and the Office of Quality leadership team to execute the QPS plan and strategic priorities by using methodologies of improvement to drive improvements of clinical and process outcomes related to patient safety, infection control & prevention, and other key quality performance metrics that are used to determine incentive and potential penalties as measured by CMS, private payers, and public benchmarking of system performance Maintains/obtains knowledge and then provides education regarding the relationship of quality with patient experienceCollaborates with other OU entity CQOs and service line QPS leads as needed to foster high reliability and standardizationDevelops, plans, coordinates, and implements strategic and day-to-day quality (clinical improvement) programs at OU entityCoordinates and oversee all survey activities, policy management, and regulatory reporting to ensure that full accreditation, certification, and licensure are maintained in all OU entity facilitiesCollaborates with local hospital operating unit leaders, academic departments, and service line QPS leaders to ensure integration of clinical quality management, regulatory compliance, patient safety, and risk management efforts across system Partners with Director, Quality & Patient Safety staff in adherence with EHC policies and standards with the responsibility coaching, mentoring and performance management of staffSupports the Patient Safety Quality Committee of the Board of Directors of the system Participate in organizational committees at both the hospital and system committees as assigned or neededQuality:Anticipate national trends and initiatives in performance improvement, clinical quality, health care informatics, and the use of clinical technology for improvement effortsProactively reviews and analyzes key quality metrics and identifies opportunities for process improvementCollaborates with the Quality & Patient Safety team and OU entity executive team for performance measurement, attainment of goals and performance of improvement activities to achieve maximal gain in healthcare outcomesProvides direction, and collaborates with leadership, to inform clinical informatics usage and electronic health record optimization to ensure quality, safety, and performance excellenceUtilize data analytics to ensure consistent feedback is provided for all involved care providers regarding specific patient experience and quality performance resultsFosters the achievement of OU entity quality goals while addressing deficiencies that might lead to penaltiesEnsures OU entity implements and are well positioned for local, state and national clinical regulatory programs, value-based purchasing methodologies, and comparison ratings, including, but not limited to US News and World Report, CMS Star ratings, and LeapfrogRepresents the department at report-outs with OU entity leadership, QPS leadership, board of trustee meetings, and other relevant executive meetingsRegulatory Accreditation and Certification:Provides leadership regarding regulatory standards practice policies, and compliance: regulatory body hospital-wide review/surveys (the Joint Commission, DCH, etc.) as well as surveys for disease-specific certificationsServe as a physician QPS lead during regulatory surveysMonitor and promote actions to achieve compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and health system policiesInterprets, educates and assures hospital compliance with rules/regulations of The Joint Commission, CMS and any other regulatory agency with regards to quality of care and patient safetyPolicy Management:Facilitate the dissemination, communication, and implementation of policies and proceduresInfection Prevention:Partners with Infection Control & Prevention leaders to implement facility IPC strategy and provide leadership of the Infection Prevention program and efforts at OU entityPatient Safety:Leads the patient safety efforts at OU entity in partnership with the Director, Quality & Patient Safety and OU entity leadershipOversee all significant adverse events and mortality reviews in collaboration with the respective QPS team and relevant academic department and service line QPS leadsInvestigate all major adverse events in collaboration with Patient Safety ManagerApprise CQO and VP QPS of all high-level, high harm serious adverse eventsOversee all other adverse events, including near-misses, deaths and complaints or grievance with a quality concern in a timely (per regulatory requirements) and thorough fashionRefer non-clinical events to Patient Services Administration or other relevant departments Root Cause AnalysisLead RCA preparation alongside Patient Safety ManagerConsult with service line or academic QPS on events relevant to their departmentLead the RCA meeting as well as pre-and-post serious event meetingsOversee plans of correction to ensure the service line and academic department has meet accountability and responsibility of correction standards Work collaboratively across the organization to oversee the review and response to patient safety events, mortalities.Serve as a primary resource during the patient safety debrief as well as lead the relevant Root Cause Analyses Foster an environment that supports a Just Culture, in which staff members feel safe to report errors and participate in the analysis and mitigation of errorsQuality Data Strategy and Program ReportingProvides leadership and input of clinical quality data strategy for improvements in collaboration with data analytics team and information technology teamProfessional Performance Evaluations and Peer Review AnalysisMaintain physician credentialing, re-credentialing, and to meet regulatory performance evaluationsQuality Education:Serve as an expert in the education of staff and clinicians in the science of improvement, quality and patient safetyPartner with GME office and DIO to support trainee education and experienceKey Relationships:Serve as physician quality and patient safety leader for their respective campus under the direction of the VP, Quality and Patient Safety Partner with the Local and Service Line QPS teamsPartner with the hospital, nursing, clinical leadership, digital technology, informatics teams Partners with key provider networks to ensure communication and continuity between care settings (including voluntary (non-employed) providers where applicable)MINIMUM QUALIFICATION:Medical degree from an accredited institution; board certification in medical specialtySeven (7) years of progressive leadership in healthcare quality related positionExperience with the design and implementation of quality, performance improvement and patient safety efforts in a complex health systemLeadership experience in a complex, highly matrixed, academic health system for at least five (5) years at the corporate or health system levelPreferred Qualification:Masters degree level degreeCertified Professional in Healthcare Quality (CPHQ), or Lean or Six Sigma Black Belt designation

Created: 2025-03-03