Major Responsibilities:

• Accountability and Functions:
  • Is accountable to the President of the Medial Hospital and the Vice President of the Medical Management ("VPMM") for his employment and responsible to the President of the Medical Staff and VPMM for all professional and clinical activities within the realm of his responsibility.
  • Is responsible in conjunction with the Department Chairpersons, for overseeing the quality of care provided by the medical staff, especially as it relates to opportunities for improvement. The Medical Director of Quality will be an ex-officio member of the Medical Executive Committee ("MEC").
  • Will support and contribute to the Hospital's mission, values and philosophy.
  • Will have excellent communication skills; will practice and create an environment that supports and sustains effective communication.
• The Medical Quality Director will:
  • Serve as chairperson for Medical Quality Committee.
  • Oversee and coordinate the activities of the Medical Quality Committee, assuring timely review of cases as identified by the screening criteria, timely and appropriate discussion for cases identified by the reviewing medical staff department representative, as well as cases that require multidisciplinary review. In consultation with the medical staff and administration, as appropriate, assigns members to teams for resolution of issues that indicate the need for process improvement.
  • Be responsible for oversight, implementation and administration of the National Surgical Quality Improvement Program ("NSQIP") at Good Shepherd Hospital. Responsibilities include initial and ongoing support for the surgical clinical reviewer and the promotion and advancement of the program, participation in conference calls, attendance at the American College of Surgeons NSQIP Annual Conference, and collaboration with Director of Perioperative Services and the Department of Surgery Chairperson in improving quality of care and outcomes in the surgical patient.
  • Support and lead change efforts related to performance improvement, compliant documentation management, and patient safety concerns and/or initiatives. Report the results of peer review and improvement teams, to the MEC on a quarterly basis, making recommendations as appropriate to implement changes to improve care.
  • Utilize outcome of peer review and performance improvement findings to provide education to the medical staff.
  • Transmit recommendations, in conjunction with the department chairperson, from the Medical Quality Committee, to the MEC, concerning clinical performance.
  • Keep current in knowledge of and ensure compliance for regulatory and accrediting agencies.
  • Actively participates in accreditation and regulatory surveys.
  • Partner with patient care services and administration in matters affecting patient care, including patient satisfaction, and cost containment.
  • Attend Quality Management Oversight Committee, Patient Safety and MEC meetings and be available to attend department meetings as requested by department chairpersons.

Licensure:

• Physician

Education/Experience Required:

• Graduate of an accredited medical school. Minimum of 5 years recent experience in clinical practice.

Knowledge, Skills & Abilities Required:

• Current Illinois license to practice medicine and eligibility for active membership on the hospital's medical staff.

Physical Requirements and Working Conditions:

• Ability to travel to various hospitals and Advocate locations, including patient care areas, conference facilities, Advocate Health System offices and other sites as requested.
• Embraces changing paradigm for enterprise care management and the need to act in a more coordinated and integrated fashion across the enterprise
• Willing to be accountable for KRAs related to managing LOS, resource utilization (cost), readmissions.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.