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The Chief Quality & Medical Officer Hospital Channel is responsible for ensuring the delivery of exceptional care quality including infection prevention and continuous real-time preparedness and readiness for regulatory and accreditation and certification surveys and system disaster response with the goal of achieving and maintaining substantive compliance with CMS Conditions of Participation and state licensure requirements within the hospital channel. In addition, this officer will work in close collaboration with the System CMO/CNE and each of the hospital leadership teams to deliver clinical differentiation within the hospital channel.  This includes the attainment of service line quality metrics, patient safety performance, risk management mitigation and reliable medical staff credentialing. The direct reports to this position include hospital channel level Senior Directors of Infection Prevention and Regulatory Operations; and the System Infectious Disease Physician Advisor. This position is also responsible for maintaining tight alignment and integration of all joint-venture hospitals within the Texas Health ecosystem regarding quality improvement, management, regulatory/accreditation and licensure activities, and infection prevention.    

Essential Functions:

         Responsible and accountable for the successful deployment, execution and sustainability of all  relevant system strategies, tactics and action plans in the Hospital Channel, and doing so in accordance with the specifications established by the system's executive leadership.

         Responsible for contributing to the achievement systemwide hospital channel key performance indicators (KPIs) and key performance measures (KPMs) related to clinical quality improvement, clinical differentiation and harm reduction.

         Work collaboratively with the System CMO, CNE, and relevant system leadership to support design and deployment of system service line, patient safety, and risk management initiatives, ensuring that reliable patient safety, risk management and service line measures are appropriately provided and administered within the hospital channel.

         Ensure highly reliable medical staff credentialing across the hospital channel, including coordination of credentialing reports to QPC and other relevant bodies. Work in close conjunction with system credentialing office to design and deploy standardized and reliable credentialing processes. ,

         Leads the design and implementation of the Hospital Channel Quality Improvement Plan and serves as the hospital channel representative to  the Quality and Performance Committee (QPC) of the Board. 

         Responsible and accountable for the design, deployment and ongoing refinement of proactive risk assessments and "early warning systems" to detect material gaps in delivery of exceptional care, with multidisciplinary teams convened to develop and execute appropriate corrective action plans.

         Responsible and accountable for maintaining regulatory compliance, accreditation and licensure of all assets within the Hospital Channel, including the design and implementation of policies and processes necessary to ensure continuous real-time survey readiness and substantive compliance with all external standards and requirements.

         Responsible for performance and accountability management of all direct reports based on annual operating plans that set forth clear and measurable goals, priorities, objectives and key results that are tightly aligned with system strategies, tactics, action plans, deliverables and specifications.

         Responsible for successful alignment and integration of all joint-venture hospitals in the Texas Health ecosystem regarding quality management, accreditation/licensure activities, and infection prevention, through collaboration with the leaders and quality directors et al of each joint venture.

         Responsible for establishing systematic and highly reliable processes for the identification and sustainable spread of better practices throughout the Hospital Channel; continuously improving the effectiveness, efficiency and productivity of all resources with this role's span of control and spheres of influence; reducing or eliminating avoidable waste; improving ease of use; and, successfully deploying standardized policies, procedures, practices and processes throughout the Hospital Channel.

         Serve as a role model of Texas Health's mission, vision, values, leadership behaviors, Promise standards and Code of Business Ethics; practice servant leadership with a focus on collaboration.

Individuals must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.  This role requires the ability to solve problems, think outside the box, and be resourceful; must be result-oriented, a quick learner and a self-starter.  The requirements listed below are representative of the knowledge, skill, and/or ability required to build THR's culture for action.

Background, Qualifications and Experience:

• M.D. or D.O. required or

• 10 years' progressive leadership experience in medical staff leadership, quality improvement, management, and accreditation and regulatory compliance required.
• 5 years' experience in a complex health system and/or integrated delivery network required.
• Must have knowledge and understanding of issues facing the delivery of healthcare across the continuum of services.

Desired Personal Characteristics:

• Is mission-inspired ~ models a passionate commitment to the Mission of THR, and ensures the long-term viability of our mission through decision-making and inspires others to do the same. Demonstrates the ability to integrate the core values of respect, integrity, compassion, and excellence into programs and services.
• Embodies shared leadership and is a collaborative, deliberate and direct decision-maker.  Has a record of functioning as a high-impact, low-ego leader who thrives in a team setting, motivated by the advancement of the organization, as well as representing a strong role model and mentor.
•  Displays innovative thinking with vision.  Displays excellent conceptual and planning skills appropriate to a position with responsibility for highly reliable health care delivery services.
• Possesses a balanced understanding of clinical, business, and management requirements for various types of health care services, including knowledge of integrated delivery systems. 
• Demonstrates superb interpersonal and communication skills to effectively engender confidence and trust. 
• Has tenacity and perseverance in the face of challenges and can overcome obstacles to get things done.  Approaches and deals with conflict creatively and constructively.
• Builds credibility and drives outcomes at the highest level; is able to operate effectively within a complex and diverse organization.
• Demonstrates proven ability to lead organizations in the development and implementation of large scale change efforts through influence - creating broad organizational buy-in, excitement and commitment.