Chief Quality Officer, Ambulatory - Emory Healthcare

The Chief Quality Officer, Ambulatory Provides oversight, development and administration of local OU entity quality management, performance improvement, and regulatory compliance activities, to achieve Emory Healthcare (EHC) 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 evaluations

Primary Duties and Responsibilities:

• Collaborates with the EHC CQO and the Office of Quality leadership team to execute the EHC QPS plan and EHC 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 EHC performance Maintains/obtains knowledge and then provides education regarding the relationship of quality with patient experience
• Collaborates with other OU entity CQOs and service line QPS leads as needed to foster high reliability and standardization
• Develops, plans, coordinates, and implements strategic and day-to-day quality (clinical improvement) programs at OU entity
• Coordinates and oversee all survey activities, policy management, and regulatory reporting to ensure that full accreditation, certification, and licensure are maintained in all OU entity facilities
• Collaborates with local hospital operating unit leaders, EU academic departments, and service line QPS leaders to ensure integration of clinical quality management, regulatory compliance, patient safety, and risk management efforts across EHC Partners with Director, Quality & Patient Safety staff in adherence with EHC policies and standards with the responsibility coaching, mentoring and performance management of staff
• Supports the Patient Safety Quality Committee of the Board of Directors of EHC Participate in organizational committees at both the hospital and system committees as assigned or needed

Quality:

• Anticipate national trends and initiatives in performance improvement, clinical quality, health care informatics, and the use of clinical technology for improvement efforts
• Proactively reviews and analyzes key quality metrics and identifies opportunities for process improvement
• Collaborates 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 outcomes
• Provides direction, and collaborates with leadership, to inform clinical informatics usage and electronic health record optimization to ensure quality, safety, and performance excellence
• Utilize data analytics to ensure consistent feedback is provided for all involved care providers regarding specific patient experience and quality performance results
• Fosters the achievement of OU entity quality goals while addressing deficiencies that might lead to penalties
• Ensures 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 Leapfrog
• Represents the department at report-outs with OU entity leadership, EHC QPS leadership, board of trustee meetings, and other relevant executive meetings

Regulatory 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 certifications
• Serve as a physician QPS lead during regulatory surveys
• Monitor and promote actions to achieve compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and health system policies
• Interprets, 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 safety

Policy Management:

• Facilitate the dissemination, communication, and implementation EHC policies and procedures

Infection Prevention:

• Partners with Infection Control & Prevention leaders to implement EHC IPC strategy and provide leadership of the Infection Prevention program and efforts at OU entity

Patient Safety:

• Leads the patient safety efforts at OU entity in partnership with the Director, Quality & Patient Safety and OU entity leadership
• Oversee all significant adverse events and mortality reviews in collaboration with the respective QPS team and relevant academic department and service line QPS leads
• Investigate all major adverse events in collaboration with Patient Safety Manager
• Apprise EHC CQO and VP QPS of all high-level, high harm serious adverse events
• Oversee all other adverse events, including near-misses, deaths and complaints or grievance with a quality concern in a timely (per regulatory requirements) and thorough fashion
• Refer non-clinical events to Patient Services Administration or other relevant departments Root Cause Analysis
• Lead RCA preparation alongside Patient Safety Manager
• Consult with service line or academic QPS on events relevant to their department
• Lead the RCA meeting as well as pre-and-post serious event meetings
• Oversee 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 errors

Quality Data Strategy and Program Reporting:

• Provides leadership and input of clinical quality data strategy for improvements in collaboration with data analytics team and information technology team

Professional Performance Evaluations and Peer Review Analysis:

• Maintain physician credentialing, re-credentialing, and to meet regulatory performance evaluations

Quality Education:

• Serve as an expert in the education of staff and clinicians in the science of improvement, quality and patient safety
• Partner with GME office and DIO to support trainee education and experience

Key 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 teams
• Partner 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 specialty
• Seven (7) years of progressive leadership in healthcare quality related position
• Experience with the design and implementation of quality, performance improvement and patient safety efforts in a complex health system
• Leadership experience in a complex, highly matrixed, academic health system for at least five (5) years at the corporate or health system level

Preferred Qualification:

• Masters degree level degree
• Certified Professional in Healthcare Quality (CPHQ), or Lean or Six Sigma Black Belt designation