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Chief Quality Officer - Willowbrook Campus

Job Ref: 12534

Talent Area: MD or DO

Houston Methodist Hospital
Houston, TX 77030

Area/Department: MPO Administration

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist Willowbrook Hospital opened its doors to Northwest Houston in December 2000. In May 2010, a major expansion on the 52-acre campus doubled the size of the hospital, brining more expertise, more state-of-the-art technology and more specialized care to the community. With 251 licensed beds, 14 operating rooms and over 1,400 employees, Houston Methodist Willowbrook Hospital was specifically designed to provide comprehensive, personalized care for the community.

Job Summary

SUMMARY: The Houston Methodist Hospital Chief Quality Officer (CQO), in conjunction with the CEO and Houston Methodist System Chief Quality Officer, is responsible for implementing the Houston Methodist vision and strategy for excellence in clinical quality outcomes, value, and patient safety. The CQO collaborates with other system physician leadership in quality and patient safety to support the development of the strategy and goals for leading unparalleled quality and patient safety at Houston Methodist.

The CQO assures that safe and reliable processes are embedded into the delivery of health care, and develops a culture which values patient safety, clinical excellence, evidence-based medicine, and continuous learning. The Chief Quality Officer (CQO) reports to the System Chief Quality Officer of Houston Methodist, with a dotted line reporting to the entity Chief Executive Officer (or his/her designee).  The CQO works in close collaboration with the entity Director and/or VP of Quality and Patient safety, and collaborates with all disciplines, hospital leadership, and the medical staff to promote identification of organizational vulnerabilities, health care design using human factors and system principles, and learning to understand and prevent adverse events, achieve high reliable processes, and outstanding clinical outcomes.  These activities are estimated to require an average of 20 hours per week.  The CQO is responsible, along with other member of the HM team, to ensure that HM¿s unique combination of resources is used wisely to fulfill its responsibilities to its community, to enhance its premier position in the marketplace, and to ensure its continuing leadership in medicine. 

1. Oversees and directs the development of a comprehensive quality and patient safety program with practice guidelines.  Collaborates with physicians and Hospital Leadership in coordinating quality and safety initiatives.
2. Participates in orienting Medical Staff and other hospital staff members to policies and procedures related to quality and patient safety.
3. Provides communication and education to the Medical Staff, Hospital Leadership and Staff, and Board of Trustees regarding the activities of the program.
4. Communicates with CNO regarding services and clinical enhancements necessary to maintain or achieve a safe, high quality patient care environment.  Provides appropriate medical direction in accordance with all applicable hospital policies and procedures.
5. Work with CQO¿s of HM including TMHPO to integrate Quality programs throughout the Houston Methodist System and throughout the continuum of care.
6. Promotes a collaborative environment with directors, physicians and staff.
7. Provides physician leadership to the quality staff in preparation and review of cases for peer review as needed.
8. Supports and enforces behavior standards and procedures for medical staff as it relates to factors that contribute to adverse events and quality of care improvement.

1. Support and implement a Quality and Patient Safety strategy that links delivery of clinical care with education and research, adopting management and operations processes that maximize function and minimize administrative overhead.

1. Oversees a comprehensive quality and patient safety program; directs the development and implementation of evidence based practice guidelines;
2. Oversees the development of an approach to incorporate Quality, Patient Safety, Performance Improvement, Risk Management, and Infection Control.  Serves as the Physician Champion of Quality and Safety and incorporates the Medical Staff Leadership into the Program.
3. Assures compliance with the regulatory agencies in the design and execution of the program.
4. Assures compliance with hospital and other regulatory safety requirements.
5. Oversees investigation and internal reporting of sentinel events and serves as physician champion in PI efforts related to Patient Safety.  Serves as the primary investigator for Medical Staff interviews for sentinel events and other medical care questions.
6. Serves as Co-Chair of the Quality and Patient Safety Steering Committee.
7. Participates in accreditation and other surveys as appropriate.
8. Provides appropriate medical direction in accordance with all applicable hospital policies and procedures.
9. Collaborates in the governance over development of physician order entry, bar coding, clinical decision support, safe medication delivery, and other devices in the delivery of clinical care.
10. In conjunction with System CQO, prepare an annual report on patient safety for the Board of Directors at the end of each fiscal year that includes:
a. A summary and evaluation of patient safety activities in the clinical departments,
b. Results of reviews of patient medical records, adverse events, complaints and lawsuits,
c. Recommended policies, procedures, processes, guidelines, and standards and progress with their implementation and measurement of improvement,
d. Corrective actions taken to improve patient safety, and
e. Goals for the next fiscal year.

1. Attends meetings of the Medical Staff to educate and coordinate the activities of the quality and safety program.
2. Provides communications and education to the Medical Staff, Hospital Leadership and Staff, and Board of Trustees regarding the activities of the program.
3. Work with HM Information Technology (IT) staff, Quality staff and researchers, and medical staff members to develop IT strategies that will support patient care Quality and Quality research. 
4. Supports the implementation of information technology to deliver added value, and assure that implementation is accomplished for patient safety, excellent outcomes, and for acceptance by both professional and support staff.
5. Assists directors in development and revision to unit specific policies as indicated
6. Serves as liaison with medical staff to assure appropriate utilization of hospital services/resources.
7. Serves as liaison between physicians and hospital unit employees.
8. Meets with Directors, CNO and CEO on a regular basis to review appropriate data relating to operations, quality of care, and patient safety, and quality of customer service.
9. Attends 75% of care management meetings and Department meetings.
10. Actively participates in Services meetings and other meetings as needed.

1. Develops long-range goals, annual objectives, and strategies for the Hospital, Quality and Patient Safety Program.  Active participation in the recruitment of medical staff to meet long term objectives. 
2. Set strategic, patient/customer-oriented priorities and goals.  Give direction and guidance to management and staff to achieve the highest possible patient/customer satisfaction.
3. Collaborates in the development of physician order entry, bar coding, and other devices in the delivery of clinical care.
4. Develop and deliver educational and training programs for all clinical faculty and staff, as well as management and Board members.
5. Develops an approach to incorporate all aspects of Performance Improvement, Risk Management, Environmental Safety, and Infection Control.

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Houston Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.

Current Medical Degree

Previous experience as Quality executive preferred.  Experience in academic medicine is preferred for entities with academic training programs.

Licensed physician in the state of Texas.  Board certified in area of specialty.

This individual must:
1. Be an active category member of the medical staff
2. Be board-certified in a medical specialty. 

In addition to the above requirements, the individual in this position may not, during his or her term of office, be a medical staff leader, such as a medical staff officer or specialty service or department chair or chief, at any other hospital.

1. Knowledge of fundamentals of patient safety.
2. Knowledge of fundamentals of quality improvement.
3. Knowledge of organizational strategies and operational objectives.
4. Knowledge of the industry and impact of the department on overall objectives.
5. Skill in coaching, counseling and developing others.
6. Knowledge of management principles, process and procedures.
7. Skilled in team building, team participation, and achieving organizational success.
8. Strategic thinker, insightful decision maker.
9. Ability to analyze and solve problems.
10. Skilled in verbal and written communication.

The Chief Quality and Safety Officer will receive an annual performance evaluation.  This evaluation will involve participation from physicians, nursing staff, unit/department staff, senior leadership, and system leadership.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.