ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Bend Chief Medical Officer

REPORTS TO POSITION: Chief Clinical Officer, SCHS (Direct)

Chief Operating Officer, SCHS (Indirect)

DEPARTMENT: Bend & Redmond Hospital Administration

DATE LAST REVIEWED: October 2022

OUR VISION: Creating America's healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

POSITION OVERVIEW: The Chief Medical Officer partners collaboratively with the Bend Chief Nursing Officer and medical staff executive leadership and the broader medical staff to improve the experience of physicians, providers and caregivers and achieve clinical and operational excellence. The Chief Medical Officer is responsible for quality, medical staff relationships, patient flow, and other administrative oversight at the hospital level. The position facilitates communication and understanding among the various clinical components of the delivery system, assuring the provision of high quality, efficient and safe care. The position collaborates with Quality and Risk at the hospital level and participates in strategic planning, annual goal setting, and prioritization of activities across the two hospitals. The Chief Medical Officer provides collaborative leadership for the Chief Medical Officer for Redmond and many of the hospital's medical directors. St. Charles Health System aspires to be a lean organization and leaders embrace the principles and behaviors consistent with lean leadership. Promoting the adoption of lean management and the development of lean leadership amongst physicians is an important aspect of the role.

In this role, he/she has matrixed accountability to the Chief Operating Officer and works interdependently with the Chief Nursing Executive and Service Line executives and leaders. The Chief Medical Officer also participates in system clinical leadership structures to improve patient flow within and between campuses and reduce unwarranted clinical variation across the system, helping prepare the organization to transition to one that successfully manages population health risk and succeeds in a value-based reimbursement marketplace. All actions are aimed to assure better, safer care and enhance the environment for practicing clinicians with the goal of providing patient centered, perfect care.

The Chief Medical Officer will serve as an administrative liaison between administration and the elected medical staffs at all St. Charles Bend and (in collaboration with the Redmond CMO) Redmond hospitals; maintaining the professional portion of the accreditation and licensure and represents hospital's Medical Staff in system-related matters. The Chief Medical Officer supports the Chief of Medical Staff by providing leadership in all aspects of medical affairs with particular emphasis on clinical care and efficiency across the care continuum. One of the key objectives of this position is to provide skilled management and leadership for the organized medical staff and physician organizations that result in effective governance, credentialing, planning, monitoring, and improving the quality of patient care and resource utilization.

This role also oversees the centralized medical staff office and is responsible, either directly or through delegation, for all medical staff processes such as ongoing and focused professional practice evaluation (OPPE and FPPE, respectively).

ESSENTIAL FUNCTIONS AND DUTIES:

Leads Clinical and Operational Excellence

• Actively participates as a member of the St. Charles Health System Bend/Redmond Executive team. In conjunction with the elected medical staff leaders, medical directors, the Hospital Administrator, and the Chief Nurse Officer, is accountable for the quality of care delivered at St. Charles Bend hospital.

• In conjunction with the Director of Quality, develops and implements quality improvement plan for the hospitals. Assists the Quality Department in investigations and responds to concerns about quality issues expressed within the facility, from government agencies, staff, and other external entities.

• Works directly with hospital patient safety leadership in implementation of patient safety initiatives by advising the Hospital Administrator, Chief Nurse Officer, and medical staff about patient safety and quality outcomes.

• Works collaboratively across the system of care to ensure the timely transfer and flow of patients to and from the St. Charles Health System Bend and Redmond campuses, partnering with the Patient Flow and Transfer Center leadership, and ensures the patient transfer/referral process is compliant with EMTALA.

• Demonstrates knowledge of current Joint Commission requirements and regularly participates in preparation activities. Supports the concept of continual readiness for regulatory reviews and leads by example. Serves as the physician leader during survey and is expected to interact with the survey team with the highest degree of professionalism and integrity.

• Monitors trends in clinical outcomes, evidence-based medicine, utilization, cost-effectiveness, and quality/service outcomes, makes recommendations for action and influences improvement projects as needed.

• Monitors the integration of all care necessary to meet patients' healthcare needs through review of trending data, works with the hospital's informatics department to assure that data on quality of care are timely and useful. Engages with hospital and system leadership to assure that quality data are presented in a consistent and meaningful format.

• Participates in the evaluation of the new program services and initiatives considered by the facility, including development and monitoring of best practices for all new services.

• Serves as an active participant in strategic planning and budgeting process for the Bend and Redmond hospitals conveying needs of physicians and other clinicians tempered by economics, staffing and political considerations.

• Oversees, directs, and integrates all aspects of quality and relevant medical staff activities within Care Management.

• Participates in Sentinel Event/Crisis Adverse Event investigations and corrective activity.

• Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.

• Hires, directs, coaches, and monitors the performance of all direct reports, to develop and maintain a high-performance team that meets organizational and department goals.

• Monitors and ensure all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals.

Supports and helps lead Medical Staff

• Influences and engages the medical staff in the improvement of the quality of patient care. This includes both the quality of medical care and humanistic services rendered.

• Works directly with Medical Staff and Executive Team to provide ongoing and immediate access to clinicians and services provided at the hospitals and proceeds with implementation as approved by the Board of Directors and Medical Staff.

• Continues and further develops positive, mutually supportive relationship between Medical Center Administration and the Medical Staff.

• Engages medical staff leadership in maintaining high quality medical staff and help lead the medical staff's participation in furthering the mission of the organization.

• Participates in medical staff committees to integrate the activities of the various committees with each other, and with the overall goals of the hospitals.

• Attends hospital and system wide committees as required.

• Develops and maintains effective working relationships with the St. Charles Health System organized medical staff leadership, in particular the Chiefs of Staff, other members of the Medical Executive Committee, and supervises Medical Directors to assist in providing delivery of care that is in the best interest of the patient. Develops and sustains effective relationships with colleagues in other affiliates and regions to share and learn best practices.

• Provides consultation to medical staff leadership in areas of disciplinary action, legal concerns, privileging, and regulatory requirements.

• The Chief Medical Officer serves as the principal interface between physicians and other practitioners and Administration. The Chief Medical Officer serves as a clinical voice with Administration representing opinions of practitioners and conversely, helps the Medical Staff understand the rationale for administrative decisions.

• Oversees system-wide program for physician Call Pay, working with Medical Staff Leaders to assure adequate coverage of all necessary specialties within the system.

• Provides support for and actively participates with the Chiefs of the Medical Staff and the Medical Staff Executive Committees of St. Charles Health System Hospitals, especially in areas of credentials, utilization, quality management, patient safety, peer review, medical staff re-engineering, by-laws, and risk management and cost reduction.

Oversees Medical Directors and Medical Staff Office

• Has direct oversight of specified hospital medical directors to assure optimal safe and effective care. Engages with hospital-based physicians (ED, hospitalists, radiologists, etc.) to provide safe, timely, efficient, and effective patient throughput.

• Provide administrative oversight of the Medical Staff Services office.

Provides Medical Leadership

• Represent the hospital on assigned internal and external committees, task forces, commissions, agencies and by promotional or public relations efforts regarding medical affairs. Also monitors and interprets legislative and administrative activities which may impact the medical staff and the organization.

• Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

• May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:

Required: Doctorate Degree (MD or DO).

Preferred: Master's in Business, Medical Management or Public Health.

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Oregon Physician licensure eligible. Board certification in primary field. Valid Oregon driver's license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites.

EXPERIENCE:

Required: Ongoing clinical practice (0.2 FTE) within a hospital setting is expected; a minimum of 5 years in clinical practice with previous experience as a CMO, VPMA or elected medical staff president position; prior experience demonstrating effective organizational performance improvement skills, in-depth working knowledge of integrated healthcare organization and administration, agency standards/compliance, and laws applicable to healthcare operations; must have experience integrating various components and support systems of healthcare into a functional continuum of care.

Preferred: A minimum of 5 years of administrative experience: prior experience demonstrating effective management of a hospital at the top physician executive level; lean experience.

KNOWLEDGE:

Required: A thorough knowledge of healthcare administration and care delivery models with knowledge in finance, planning, physician relations, human resource management, and nursing collaboration; thorough knowledge of regulations affecting healthcare delivery; must have familiarity with healthcare administration in a managed care environment; knowledge of all aspects of hospital operations and Oregon health care market, federal and state regulations, TJC, CMS and related accreditation standards.

SKILLS:

Required: Excellent team leadership and organizational skills are required; an ability to prioritize multiple demands and projects is critical; excellent written and oral communication and interpersonal skills; must be adept at public speaking and making persuasive presentations. Must demonstrate strong business acumen, entrepreneurial risk-taking ability, proactive attitude, and creativity in problem solving. Strong leadership and negotiation skills and sound decision-making ability are required. Ability to lead, challenge and motivate staff. An excellent background and ability to form strong physician relationships, as well as build strong collaboration with nursing and other key departments are required. An ability to build teams, as well as consensus is crucial. An ability to deal with complex situations and a large degree of variation in policies, rules and regulations is critical. Flexibility, adaptability, creativity, and innovation are required. Must be a self-starter with a high degree of initiative and ability to work independently. An ability to meet deadlines and implement projects effectively across multiple entities is an integral part of the work responsibilities. Demonstrated understanding of regulatory and accreditation standards and the basic issues and principles of healthcare law and the implications of the Stark Laws, Fraud and Abuse, Not-for-Profit status, and physician inurement. Demonstrated familiarity of medical staff organization, credentialing, bylaws, rules, and regulations. Demonstrated understanding of principles and implications of standards for quality of care, quality monitoring, utilization review, discharge planning and related features, including value-based reimbursement. Ability to act as a change agent to create a culture of high reliability in which changes are adopted and implemented to support the mission of St. Charles Health System. Creates an environment in which caregivers and providers feel valued, respected, and energized to explore new methods of doing business, generate revenue and take calculated risks. Demonstrated understanding of information systems and managed care markets.

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

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