St. Josephs Medical Center
Chief Quality Officer - St. Joseph Medical Center
9 days ago
Houston
Job Description JOB SUMMARY: The CQO will have oversight responsibility for all performance improvement, risk, infection control, safety, and physician peer review activities for the hospital and outpatient departments. The CQO must: • Drive quality initiatives by working with the hospital staff to direct a hospital-wide quality assessment and quality improvement program, • Develop a process to review and implement best practice to reduce variances and improve quality:, • Implement a comprehensive event reporting system, • Ensure ongoing Internal Audits for identified performance expectations, • Implement, with the assistance of Human Resources and the Medical Staff, a "Just Culture" methodology within the organization, • Develop a cause analysis and problem identification & resolution process, • Prioritize quality improvement initiatives throughout the organization, • Oversees corrective action plans for improvement efforts, • Develop a comprehensive and efficient reporting mechanism for quality data (hospital and Medical Staff) to the Board through the Quality and Safety Oversight Committee., • Support the organization's efforts to meet all JCHAO, CMS, DNV and other state and federal regulatory standards and maintains a continuous state of readiness, • Represent the hospital to outside agencies when appropriate, including maintaining a working relationship with professional review organizations, • Represent the hospital to HSA in improvement activities The CQO will also lead the evaluation of quality, safety and service delivery and support the development of improvement plans. The CQO must: • Oversee a system for patient care review that enables medical staff committees to monitor physician performance and the credentials committee to maintain appropriate physician privileges, • Facilitate leaders in their evaluation and management of issues PRINCIPAL DUTIES AND RESPONSIBILITIES: • Consistently supports the hospital and communicates the Mission, Vision and Values of St. Joseph Medical Center., • The CQO will lead the overall approach to quality, safety and service improvement in the hospitals and outpatient departments., • The CQO will also facilitate the work of medical staff leaders including medical staff presidents and department and committee chairs, specifically the CQO will lead the evaluation of quality, safety and service delivery and support the development of improvement plans., • The CQO will support medical education., • The CQO will serve as an important liaison between the medical staff and hospital administration. The CQO will foster and contribute to a close and mutually beneficial relationship between the medical staff and hospital management. Consistently supports and maintains the Mission, Core Values and expected customer service behaviors of St. Joseph Medical Center., • Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)., • Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non-punitive environment., • Develops and secures approval of and administer capital and operating budgets for assigned service area in cooperation with hospital administration. Build and improve service line and increase productivity., • Maintains cooperative working relationships with physicians, Hospital departments and employees necessary in order to obtain solutions to problems and improve coordination of services provided and improve patient, physician and employee satisfaction., • Maintains and enhances Hospital's public and employee relations efforts through contacts with patients, visitors and staff, and through investigation and resolution of complaints or concerns., • Plans and administers directly and through subordinate supervisory personnel, the effective management and delivery or quality patient care for nursing, encompassing several units and all shifts, within a broad grouping of patient services/units in accordance with department, Hospital and regulatory agency requirements., • Participates in developing department-wide goals and objectives, and in designing and implementing appropriate plans to meet agreed-upon goals in cooperation with other department managers. Assists in developing and meeting appropriate goals and objectives for each unit., • Participates in developing department-wide policies and procedures and ensures approved policies and procedures effectively. Develops and secures approval of patient policies and procedures for assigned Units., • Supportive of the compliance program set forth by SJMC and demonstrated by:, • Upholds the Code of Ethics and Corporate Compliance., • Adheres to dealing appropriately and fairly with employee misconduct., • Enforces all compliance policies as they pertain to his/her area., • Provides and assures timely compliance education as requested by the Regional Compliance and Safety Officer and/or through corporate initiatives. MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED: • Be a Licensed Registered Nurse with a master's degree in a related field and a minimum of 10 years' experience in progressive leadership, • Possesses exceptional leadership skills, including a faculty for conceptual thinking, peer motivation, and problem solving, • demonstrate significant accomplishments in quality improvement and leadership, • demonstrate the ability to work independently, • have excellent negotiation skills Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most. Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care. Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way. Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.