Associate Chief Quality Officer, Warner Robins & Perry

Key Responsibilities

• Lead hospital-based quality improvement and patient safety programs
• Implement Emory Healthcare’s Quality and Patient Safety (QPS) strategic initiatives
• Partner with clinical departments and hospital leadership to drive improvement initiatives
• Monitor performance metrics tied to CMS programs, value-based purchasing, and public reporting
• Ensure readiness for Joint Commission and regulatory surveys
• Investigate adverse events, including Root Cause Analyses and Failure Mode and Effects Analyses
• Participate in hospital and health system committees related to quality and safety

Required Qualifications

• MD or DO with an active board certification in any medical specialty
• Minimum 3 years of progressive leadership experience in healthcare quality
• Experience implementing quality improvement or patient safety initiatives

About Emory Healthcare & Emory Hospital Warner Robins

Emory Healthcare is the largest and most comprehensive academic health system in Georgia and is nationally recognized for its commitment to clinical excellence, patient safety, and quality improvement.

Job Description

• Provides leadership and support in the oversight for all aspects of quality and patient safety for their assigned facility.
• Collaborates with the EHC CQO, EHI, Inc., Office of Quality 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 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.
• Helps develop, plan, coordinate, and implement strategic and day-to-day quality (clinical improvement) programs across Emory Healthcare.
• Collaborates with local hospital operating unit leaders and EU academic departments to ensure integration of clinical quality management, regulatory compliance, patient safety, and risk management efforts across EHC.
• Manages the Quality & Patient Safety staff in adherence with EHC policies and standards with the responsibility for hiring, development, coaching, mentoring and performance management of staff.
• 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.
• Ensures OU entity implements and are well positioned for local, state and national clinical regulatory programs, value-based purchasing methodologies, and comparison ratings.
• Metrics/Data: The ACQO shall be knowledgeable of their relevant campus metrics including but not limited to, QPS goals, drive/watch metrics, other relevant operational metrics that are utilized by relevant raters and ranking systems. He/she shall Proactively reviews key metrics and identifies trends. Review them with hospital leaders. Identify opportunities for improvement and drive improvement.
• Regulatory Accreditation and Certification: Helps provide direction regarding regulatory standards and compliance: regulatory body hospital-wide review/surveys (the Joint Commission, DCH, etc.) as well as surveys for disease-specific certifications. Promote actions to achieve compliance with all relevant city, state and federal laws, government regulations, accrediting agency standards, and health system policies.
• Policy Management: Facilitate the dissemination, communication, and implementation EHC policies and procedures.
• Infection Prevention: Partners with IPC leaders to implement EHC IPC strategy and provide leadership of the Infection Prevention program and efforts at OU entity.
• Patient Safety: Leads and facilitates the patient safety efforts at OU entity in partnership with the Director, Quality & Patient Safety and OU entity leadership. Lead or facilitate cause, apparent, or common cause analysis, and FMEA. Investigate all major adverse events. Participate and/or lead patient safety debriefs. Apprise OU CMO or OU CQO of all major significant events. Facilitate the investigation of all significant adverse patient events, including complaints/grievances in partnership with patient advocates in a timely (per regulatory requirements) Root Cause Analysis, Lead, participate and/or facilitate the RCA meeting. Monitor plans of correction overseen and directed by the responsible party of the plans of correction.
• Risk Management: Partners with the risk management team to help facilitate risk management strategies to promote patient safety.
• 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. Ongoing Professional Performance Evaluations and Peer Review Analysis: Maintain physician credentialing, recredentialing, and to meet regulatory performance evaluations.