Job Description

Location: Steward Health Care
Posted Date: 4/20/2022

POSITION SUMMARY: The Chief Medical Officer (CMO) reports directly to the President and CEO of the Hospital and the Chief Medical Officer of Steward Health Care System. Within established organizational and departmental policies and procedures, the CMO assists in the development of an effective medical staff to serve the needs of the community and monitors and improves the quality of care in the Hospital. The CMO is a member of the executive team of the Hospital, who not only manages a portion of the organization, but also performs a key role in relating hospital functions, decisions, and policies to the medical staff, as well as relating medical staff opinions, attitudes, preferences, and needs to the Hospital leadership and governing body. The CMO serves as a resource to the medical staff, chiefs, and staff in credentialing, reappointment, peer review, and quality review. The CMO has oversight of credentialing, medical education where applicable, quality assurance and improvement, and patient safety / risk management at the hospital and/or the market level. He/she will work with the clinical chairs in the development of departmental vision, growth plan, and quality agenda. The CMO will coordinate and facilitate the development of cross-discipline programs and hospital-wide initiatives, as well as collaborate with the president and key senior team members on hospital/physician alignment, service line development, profitability, and new technology. The CMO works collaboratively with the Steward Chief Medical Officer and the corporate clinical leadership team to incorporate enterprise-wide agenda items, standardization practices and clinical quality programs. The CMO will serve as a liaison to the medical staff and hospital administration, and in collaboration with the larger team, creates a culture of respectful, mutual support, and extraordinary quality and service consistent with the Hospital’s strategy and values.

KEY RESPONSIBILITIES: Quality and Safety, and Patient Experience of Care: • Ensures implementation of quality and safety plans and annual goals through collaboration with the Medical Executive Committee, as well as other committees and workgroups. • Chairs Patient Safety and Clinical Quality Committees. • In collaboration with the CNO and other clinical quality team members, ensures current processes are effective and addresses shortfalls through assessment, development and implementation of protocols and practices. • Is accountable for continuous performance improvement and achievements of goals on internal and external measures. • Reviews events in the incident reporting system and participates in root cause analysis as needed, identifying, and overseeing implementation of corrective actions. • Analyzes and acts on safety trends Oversees the supervision of the patient advocate, risk and regulatory managers, performance improvement specialists, infection control staff and medical staff office directors. • Facilitates the involvement of medical staff members in the peer review process and works to improve the coordinated efforts of medical staff departments to monitor and improve care continually and systematically. • Monitors quality and safety, patient satisfaction, risk management, and utilization review, and develops performance improvement plans. • Works with clinical documentation specialists, coders, physician advisors and medical staff to ensure complete and accurate documentation. • Assists in the development of the agenda for Patient Safety and/or other clinical care committees of the Hospital Board. • (For Massachusetts Hospitals Only: Serves as the Patient Care Assessment Coordinator, accountable for reporting to the Board of Registration in Medicine).


• Ensures regulatory readiness, reviewing, and implementing policies for hospital and medical staff • Ensures completeness of medical record documentation by medical staff members. • Is accountable for timely adoption and education related to new policies and existing policies. • Assists in the submission of mandatory reports to state quality committees and/or boards where applicable. Medical Staff Office: • Supervises and meets regularly with the Director,

Medical Staff Office.

• Serves as resource regarding credentialing or medical staff issues. • Ensures medical staff is fully credentialed. • Ensures Joint Commission or DNV readiness for medical staff issues, including focused and ongoing Professional Performance Evaluation compliance. • Ensures ongoing compliance with medical staff bylaws.

Medical Executive Committee and Peer Review:

• Ensures adherence to timely and complete Morbidity and Mortality Rounds in all departments, reviews reportsand refers to Peer Review when appropriate. • Serves on Medical Executive Committee(s). • Addresses issues related to medical staff affairs. • Supports Clinical Quality Committee and Peer Review Committee.

Care Coordination and Management:

Actively participates in daily PULSE rounds to ensure excellence in clinical quality, appropriate length of stay, appropriate level of care, and minimize preventable readmissions. • Serves as physician resource on an as-needed basis for nursing, leadership, case management, and pharmacy. • Actively participates in implementation/upgrade, staff education, and ongoing evaluation of the electronic health record. • Oversees the function of the hospital Utilization Review Committee • Ensures appropriate coverage for on-call medical staff coverage as outlined in Hospital’s staffing plan


• Serves as an ex-officio member of medical staff committees • Works with the chairs, chiefs, and senior leadership team to develop departmental operational goals and facilitates implementation of business, operational, and clinical tactics necessary for growth, improvement, and attainment of hospital clinical, financial, and operational goals. • Works with clinical chiefs/chairs to develop goals and holds regular accountability discussions as well as yearend review of performance and achievement. • Serves as liaison to the Board of Directors, president, senior management team, and medical staff leadership on matters of medical care, medical staff affairs, patient safety, quality, liability risk, and case management. • Provides accessibility and effective communication vehicles for the medical staff to ensure its input on key issues such as strategic objectives, leadership and organization, and policy development. • Supports and participates in system quality and safety initiatives (e.g., QMORs, CMO Roundtable Meetings, etc.). • Partners with hospital president and medical staff leadership in recruitment and retention of medical staff. • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. • Commits to recognize and respect cultural diversities for all patients, visitors, employees, medical staff members, students, volunteers, and vendors in accordance with the Steward mission and vision statements • Communicates effectively with internal and external individuals with respect of differences in cultures, values, beliefs, and ages, utilizing interpreters when needed. • Performs other duties as assigned.


Medical degree (MD or DO) with board certification. • Current licensure or eligibility for licensure in local state of employment. • Minimum of 8 years clinical practice. • Post-graduate training in relevant fields of business or healthcare administration preferred (MBA, MPH, MMM, etc.). • Prior experience as a physician leader in a hospital clinical setting • Prior experience within an acute care community hospital setting • Strong clinical competency • Contemporary knowledge of laws, regulations, Joint Commission and/or DNV standards, state licensing, and relevant payor requirements relating to medical practice within an acute care hospital setting. • Knowledge of leading quality measurement, monitoring, and improvement programs, risk management, and utilization review • A solid grasp of hospital finance and the ability to effectively participate in strategic planning initiatives, including new program development and clinical services.


• Ability to use objective data to support his/her position and change behavior. Ability to act as a strong proponent for clinical quality – inspires others to follow. • Ability to clearly and effectively communicate new approaches to the medical staff members. • Ability to articulate the clinical quality and regulatory implications of decisions, policies, or actions. • Ability to command respect, clinically, administratively, and personally • Ability to build a collaborative, quality-oriented environment with nursing leadership • Ability to interact in a collegial manner with the medical staff, while also being able to effectively articulate his/her point of view. • Ability to develop a vision for the integration of medical care and help others believe in that vision


I. Education: Medical degree with board certification

II. Experience Progressive experience in medical staff administrative leadership, and eight years of clinical practice

III. Certification/Licensure: Licensure or eligibility for licensure in the home state

IV. Software/Hardware: Experience with Microsoft Outlook, Excel, and other office products

V. Other: Must reside or be willing to relocate to hospital/market location

Application Instructions

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