DEPUTY CHIEF of STAFF for QUALITY and HIGH RELIABILITY

DEPUTY CHIEF of STAFF FOR QUALITY AND HIGH RELIABILITY

CHIEF MEDICAL OFFICER

I. INTRODUCTION

The position is located at Navy Medicine East (NME), Portsmouth, VA or Navy Medicine West (NMW), San Diego, CA. The incumbent serves as the Chief Medical Officer (CMO), a leadership position that serves to strengthen the relationship in the region between administrative and medical staff. The CMO will be responsible for planning, organizing and directing the strategic direction for clinical quality, patient safety, and continuous process improvement within the region. The Regional CMO is responsible for coordinating and integrating the work of a variety of personnel from all commands in support of providing safe and appropriate healthcare for all beneficiaries within their regional area of responsibility.

This is a critical, high visibility position that is responsible for leading, directing and coordinating regionalstrategic direction toward inculcating behaviors of staff that demonstrate high reliability through the delivery of timely, high quality healthcare,within a learning culture of safety that empowers and equips staff through robust continuous process improvement to continually improve care delivery systems and processes. The incumbent will provide leadership and drive targeted results in the area of quality outcomes/indicators, internal and external customer satisfaction. He/she will work with a wide range of professionals, from Flag level to frontline staff, to directly drive prioritization and alignment of robust performance improvement initiatives in support of Navy Medicine’s mission and strategy. Emphasis will be on evaluation and alignment of clinical practice, clinical competency, quality of care, and staff/customer satisfaction.

II. MAJOR DUTIES AND RESPONSIBILITIES

As the Chief Medical Officer for Quality and High Reliability,the incumbent provides effective leadershipof thepersonneland is the primary advisor to both the Regional Commander (Flag Officer) and Chief of Staff (CoS (O6)). Directly influences and shapes policy execution within NME/W and its commands, in collaboration with the Navy Medicine RegionalDeputy Chiefs of Staff, the Bureau of Medicine and Surgery and Navy Medicine.

Key duties include leading the planning and organization of the strategic direction for clinical quality and patient safety through a number of programs and approaches. He/she will provide leadership and drive targeted results in the area of quality of outcomes/indicators, patient/provider/staff satisfaction, performance improvement prioritization and patient safety. The CMO Chairs the Regional Clinical Quality Collaborative Committee and works to align BUMED policy with those of the region and MTF’s, ensuring compliance with quality, safety, and regulatory requirements. The CMO is committed to developing a culture that reliably fosters and supports patient safety; a core value. The CMO is a senior clinician who works with others, including licensed independent practitioners, to maximize efficiencies and effectiveness by improving standardization of clinical and business processes, measuring performance, and developing interdisciplinary action plans.

Confers with and advises Regional Commander and Chief of Staff and exerts expertise and autonomy in planning details to achieve desired outcomes. Activities involve development of overall long and short-range operations and management plans for quality and the domains of high reliability.

The CMO collaborates with peers and interdisciplinary staff on a number of regional and Navy Medicine committees (e.g. Clinical Standards Board, Surgical Services Advisory Board, Medical Executive Committee, etc.), evaluating clinical practice protocols and guidelines. Findings and best practices are communicated to the field and facilitate related process improvement opportunities, as appropriate.

The position requires an expert knowledge of inpatient and outpatient healthcare settings, the military and civilian healthcare markets, and ability to create synergy across the directors within the NME and associated military treatment facilities (MTFs).

Tracks and trends projects identified in the strategic planning and performance improvement, quality and patient safety programs. Follows up on recommended corrective actions, as indicted, and monitors results through closure and compliance.

FACTOR 1: KNOWLEDGE REQUIRED BY THE POSITION,

1. MD or DO with Board Certification. Preference will be given to candidates with Masters in Business Administration, Public Health, or Healthcare Administration.

1. Have seven or more years of clinical practice and participation in leadership roles in medical staff organization activities (e.g. Medical Executive Committees, Credentials/Privileging, ACGME, Quality Advisor, etc.), and through management experience within a health care delivery system, preferably three to five years.

1. Knowledge of pertinent health care regulatory requirements, standards, and guidelines set forth by the Region, Bureau of Medicine and Surgery (BUMED), The Joint Commission (TJC), Commission on Accreditation for Rehabilitation Facilities (CARF), College of American Pathologists, (CAP), Occupational Safety and Health Administration (OSHA),Office of the Chief of Naval Operations (OPNAV), and Department of Defense (DoD) that apply to the delivery of medical care and the implementation of performance improvement concepts. Ability to interpret these requirements as they impact on the organization and utilize process improvement methodology to meet or exceed accreditation requirements.

1. Evaluate Clinical Practice Guidelines, high reliability measures, and clinical quality issues from The Joint Commission, Risk Management (Sentinel Events, Patient Safety Reporting, etc.) for regional trends. Communicate findings to the field and facilitate related process improvement opportunities, as appropriate.

1. The incumbent has knowledge of organizational clinical provider performance assessment and improvement theories, as they relate toOngoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), ensuring that athorough and thoughtful process is in place with substantial input from peers. Continuation of clinicians’ privileges at a hospital hinges on the quality and safety of care delivered to patients,.

1. Applies the philosophy and concepts of continuous quality improvement, high reliability, and change management in order to lead and facilitate interdisciplinary groups to evaluate and improve processes and systems that impact organizational performance and culture.

1. Knowledge of review process for clinical and administrative reports of adverse events, sentinel events, near misses or close calls, and appropriate investigative techniques and reporting process. Knowledge of medical terminology and procedures sufficient to interpret and identify medical/clinical issues and interact with medical professionals at all levels.

1. Work requires extensive knowledge of organizational structure, program’s mission, goals, objectives and functional responsibilities of Navy Medicine and subordinate commands.

1. Analyzes quality management approaches and current command culture, makes recommendations both short and long term, to implement high reliability principles and behaviors throughout the command. He/she participates in assessing and evaluating barriers to the implementation process and recommends strategies that will effectively overcome them.

1. Expert professional writing skills required to prepare written material in a clear and concise manner for all levels of audiences, including executive leaders. Demonstrated ability to develop and present informational briefs, project papers, marketing materials, and training to diverse audiences, including the executive level. Provides direction in preparation of executive level briefs about program functions, activities, and outcomes. Attends meetings with colleagues and/or other senior staff and articulates cogent facts and points of view pertinent to the subject matter.

1. Provides briefs and/or training on topics such as: High Reliability, Quality, Patient Safety, and CPI to a variety of audiences, including Commanding/Executive and Flag Officers.
2. Knowledge of component/command or equivalent organizational structure and its supporting/supported elements and programs, mission, policies, goals, and philosophies.
3. Mastery of a wide range of quantitative and qualitative methods and techniques to accomplish complex analysis. Expert knowledge is required to ensure office strategy is valid, realistic, and consistent with Navy Medicine’s Mission.
4. Excellent verbal communication skills required to effectively participate in meetings, discussions and provide formal briefings as well as conduct training. Skill in dealing effectively with people to include consensus building, negotiating, coalition building and conflict resolution.
5. Knowledge of computer systems for database design (entry, tracking, analysis and retrieval). Advanced proficiency in the use of software that supports the development of work products for CPI, including Microsoft Office, SharePoint, and Visio.

FACTOR 2: SUPERVISORY CONTROLS

This individual makes decisions and recommendations that will be accepted as authority, although higher level reviews will be necessary as required. Reports directly to Regional Chief of Staff who provides broad guidance and information in terms of defined missions and functions. Responsible for direct supervision and mentoring activities conducted by Quality Office staff assigned to the region.

Guides and directs staff who consult on both internal and external clinical outcomes/metrics, standards and regulatory agencies and requirements such as The Joint Commission.

Incumbent is delegated authority to independently plan, design, act, and carry out work assignments and to call upon other Chief Medical Officersubject matter experts to assist in resolving inquiries, gather information and make recommendations to the COS. Incumbent independently ensures projects and activities are carried out through to their conclusion. Completed work products are relied upon for soundness, accuracy, and adequacy of technical detail, and are normally not reviewed in detail. Review of work performance is primarily for accomplishment of project and program objectives; for consistency with organizational policies, philosophy, and goals; and for quality of contribution to CPI Program.

The incumbent is expected to use good judgment when applying and interpreting guidelines, rules and regulations affecting the military treatment facilities within Navy Medicine. The individual's professional standing and recognized capabilities are such that in cases of extreme urgency, any required approvals can be obtained based only on a brief outline of the proposed plan.

FACTOR 3: GUIDELINES

Guides require the use of broad judgment in researching, analyzing, interpreting and evaluating specific cases. Guidelines include the DHA policies and manuals, The Joint Commission standards, acquisition and budgetary statutes and regulations, judicial decisions, procedures, and agency directives. Policy guidelines include the Code of Federal Regulations, Defense Health Agency, and Service directed policies. The incumbent may be required to exercise experienced judgment and resourcefulness to deviate from or work with available guidelines to create new and individualized methods and procedures for problem solution.

Also, utilizes general administrative policies, management theories, business administration approaches, and health systems principles, all of which require adaptation to the issues and work of the Military Health System.

Exercises judgment and ingenuity using broad latitude to determine intent of applicable guidelines; develop policy and guidelines; brings forward policy statements and regulations based upon the interpretation of guidelines, laws and policies utilized.

Optimizes scarce resources, meets customer requirements, reduces rework, improves operational capacity, and increases quality.

FACTOR 4. COMPLEXITY

The incumbent of this position must be an expert in working with a high level of independence and recognized competence in analyzing military hospital/clinic performance trends, provider practice trends, licensing and credentialing standards, and monitoring progress. The incumbent exercises judgment, creativity, foresight, and originalityand has the knowledge and ability to identify various issues and circumstances that will affect the delivery of highly reliable health care processes. Information is collected from various sources and analyzed to determine the nature and scope of problems. He/she has unique interpersonal and team building skills typical of matrix management to ensure performance is effectively and efficiently directed to team purposes.

Activities involve the interpretation and implementation of regulatory standards, instructions, and directives. The work involves the development of innovative approaches or modified techniques to resolve numerous situations which may arise. The incumbent provides direction and guidance to subordinates, teams/groups/committees as appropriateconcerning decision making through the application of numerous tools or elements, often requiring extensive analysis. Decisions about how to proceed are complicated by resource restrictions and changes affecting program goals.

FACTOR 5: SCOPE AND EFFECT

The purpose of the work involves leadership, consulting and providing expertise and advisory services to agency officials and customers worldwide on the delivery of healthcare, effectiveness, and efficiency of program operations throughout the Region with some replication across the Navy Medicine Enterprise. Work contributes to the improvement of healthcare quality, patient safety, productivity, effectiveness, and efficiency in program operations and/or administrative support at small and large activities at different echelons and/or geographical locations within Navy Medicine. Work affects the plans, goals, and effectiveness of missions and programs at these various echelons or locations.

The purpose of the work is to also provide authoritative information and analysis to identify, interpret, and develop alternatives and approaches to a broad range of complex health services delivery initiatives, provider practice, and health services management practices.

FACTOR 6: PERSONAL CONTACTS

There are regular personal contacts with high level managerial and healthcare personnel within the activityand officials within Bureau of Medicine and Surgery and Navy Medicine Military Treatment Facilities. Personal contacts may occur with other federal agencies and private industry in regard to the Navy Medicine Quality and High Reliability Program and Strategic Planning. The incumbent is required to travel occasionally to attend conferences, major meetings, information presentation, and training seminars.

FACTOR 7: PURPOSE OF CONTACTS

To justify, defend, negotiate, or settle matters involving significant or controversial issues and/or programs. Work usually involves active participation in conferences, meetings, hearings, or presentations involving broad problems or issues of considerable consequence or importance. Persons contacted typically have diverse viewpoints, goals, or objectives requiring the employee to achieve a common understanding of the problems and a satisfactory solution by convincing them, arriving at a compromise, or developing suitable alternatives.

FACTOR 8: PHYSICAL DEMANDS

The work is primarily sedentary; however, there will be requirements to travel by car, bus, train, or plane to CONUS and OCONUS commands. A valid passport is required at all times. Considerable time will be spent reading information from a computer monitor and from printed materials. Must possess the stamina to cope with moderate to high stress associated with the collection, dissemination and proper presentation of proposed actions. Short deadlines with unclear, changing, and/or ambiguous guidance may increase stress.

FACTOR 9: WORK ENVIRONMENT

Work is predominantly performed in an administrative office setting, conference setting, or in an external area or facility. Routine visits are occasionally required to other work locations in the Region for the purpose of conducting program management activities, data collection, interview, collaboration, problem solving, and presentations. Travel is required to primarily CONUS and possibly OCONUS activities within Navy Medicine when requested by higher authority. A current passport is required. Employee will require a favorably adjudicated ANACI background investigation suitable for a secret clearance.

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