Position: Chief Quality Officer Location: Jackson, Tennessee Reporting Relationship: The Chief Quality Officer will report to Jackie Taylor, M.D., Chief Physician Executive of West Tennessee Healthcare. Website: https://www.wth.org/
The Organization West Tennessee Healthcare (WTH) is trusted with the health and wellbeing of more than half a million people living across 9,000 square miles of West Tennessee. It's a trust built over more than 70 years by the thousands of compassionate physicians, nurses, and care givers working in more than 90 locations that make up West Tennessee Healthcare. The organization is based in Jackson and has locations in Paris, Jackson, and Dyersburg.
As a public, not-for-profit healthcare system, West Tennesseans depend on WTH for a lot, including:
Treating more than 185,000 patients in 7 emergency rooms
Providing the highest level of newborn care with the region’s only level 3 Neonatal Intensive Care Unit (NICU)
Delivering more than 4,000 babies
Treating more heart attacks than any other hospital in the state, and over 9,000 heart patients each year
With a full continuum of care, West Tennessee also provides:
The region's only certified comprehensive cancer center
The region's most comprehensive care for kids
The region's only Joint Commission certified stroke center, providing lifesaving interventions when every second counts.
West Tennessee Healthcare History The need for a new, modern hospital in Jackson, Tennessee, became critical during World War II, as the population in the area grew. Three small community hospitals operating at the time were combined to form a 123-bed hospital with 166 employees due to the persistence of civic clubs, local leaders, and the Tennessee General Assembly. The Tennessee legislature created the private act in 1949 to form Jackson-Madison County General Hospital District (“the District”) to provide a full range of healthcare services for the needs of low income and indigent patients. Jackson-Madison County General Hospital opened the doors to treat its first patient on August 11, 1950.
The District, known as West Tennessee Healthcare, has now grown into a comprehensive health system of operating hospitals and clinics, as well as providing other healthcare services, and now employs over 7,000 people throughout the region. A Board of Trustees Appointed by the City of Jackson and Madison County is charged with the oversight of West Tennessee Healthcare. The system is completely self-supporting and does not operate on local tax revenues.
Mission To improve the health and wellbeing of the communities we serve while providing exceptional and compassionate care.
Vision To be chosen by our staff, our physicians and our community as the best place to work, the best place to practice and the best place to receive comprehensive care.
Values – WTH Cares
Continuous Improvement: We achieve innovation in clinical and operational excellence through the application of knowledge gained through discovery and lifetime learning.
Accountability: We accept responsibility for processes and outcomes so that we earn the trust and confidence of those we work with and serve.
Respect: We treat others with dignity, care and compassion, valuing diverse perspectives.
Excellence: We consistently provide the highest quality patient care experience utilizing evidence-based practices to ensure patient safety and exceptional quality and service.
Stewardship: We responsibly use the resources entrusted to us, adding value to the communities we live in and serve.
West Tennessee Healthcare Hospitals
West Tennessee Healthcare Jackson-Madison County General Hospital The flagship of West Tennessee Healthcare is Jackson-Madison County General Hospital which is a 642-bed tertiary care center that is the only tertiary care hospital between Memphis and Nashville. The hospital provides care for 17 counties of rural West Tennessee of which approximately 400,000 persons reside. Within the General Hospital, there are six ‘centers of excellence’: the West Tennessee Heart and Vascular Center, Kirkland Cancer Center, West Tennessee Women’s Center, West Tennessee Neuroscience and Spine Center, and Emergency Services. Each center has a historic reputation of ‘high-tech, high touch’ skills.
West Tennessee Healthcare Camden Hospital Camden Hospital is a 25-bed community hospital serving primary and acute care patients. It is a member of the American Hospital Association, Tennessee Hospital Association, and West Tennessee Hospital Council. Camden General is licensed by the State of Tennessee and approved by the Department of Health and Human Services for participation in Medicare and Medicaid programs. Camden General is accredited by the Joint Commission on Accreditation of Healthcare Organizations and is part of the West Tennessee Heart Network.
West Tennessee Healthcare Bolivar Hospital West Tennessee Healthcare Bolivar General Hospital is a critical access hospital with 25 licensed beds and a member of the American Hospital Association, Tennessee Hospital Association, and West Tennessee Hospital Council. They are licensed by the State of Tennessee and accredited by The Joint Commission and approved by the Department of Health and Human Services for participation in Medicare and Medicaid Programs. A wholly owned affiliate of West Tennessee Healthcare, Bolivar General Hospital is governed by a separate advisory board composed of citizens from Bolivar and Hardeman County.
West Tennessee Healthcare Dyersburg Hospital West Tennessee Healthcare Dyersburg Hospital is a 225-bed acute care facility accredited by the Joint Commission. It offers a range of medical, diagnostic, and surgical services including 24-hour emergency care, an intensive care unit, and a renovated obstetrics unit.
West Tennessee Healthcare North Hospital West Tennessee Healthcare North Hospital is a satellite of Jackson-Madison General Hospital; a 150 – bed facility providing outpatient, diagnostic, medical, surgical, and emergency care. North Hospital also offers 8 state-of-the-art operating rooms; space for 24-bed pre-operative and recovery area; and 20 patient rooms for recovering total joint patients.
West Tennessee Healthcare Volunteer Hospital West Tennessee Healthcare Volunteer Hospital is a 100-bed facility offering inpatient and outpatient care, emergency services, heart care, diagnostic imaging, pediatric medicine, physical therapy, and a range of specialties.
West Tennessee Healthcare Milan Hospital Milan General Hospital is a member of the American Hospital Association and Tennessee Hospital Association, is licensed by the State of Tennessee, and has been approved by the Department of Health and Human Service for participation in Medicare and TennCare programs and accredited by The Joint Commission. Milan Hospital has 70 acute care beds with 12 being designated as Swing Beds and 3 Critical Care Beds. It offers a wide range of primary care, acute care, intensive care, and rehab services close to home. The hospital became a wholly owned affiliate of West Tennessee Healthcare on January 1, 1998. The service area spans West Tennessee with the primary serve being Milan, North Gibson County and Carroll County.
The Opportunity Purpose of the Position The West Tennessee Healthcare’s Chief Quality Officer (CQO) position is a new and elevated role in the organization. The CQO will strategically work in partnership across the system to improve and align quality, safety, and performance improvement. The CQO is a critical and collaborative leader in supporting and implementing plans to achieve excellence.
The goal of high-quality healthcare success addresses WTH’s success in delivering on its mission as a healthcare provider. All relevant data and information is utilized to establish the organization’s performance in providing quality care. WTH is focused on improving healthcare outcomes, service delivery results, and functional status as well as achieving superior results relative to other organizations that deliver similar healthcare services.
Initial goals and priorities for the CQO include to:
Elevate quality and safety performance throughout the entire organization that continues to improve patient care and has ratings to reflect its successes.
Promote a culture of safety and quality across the system.
Establish credibility and build trusting relationships.
Serve as a change agent for WTH: identify and implement progressive, forward-thinking change to carry out clinical quality and safety objectives. Support physicians, nurses, and other team members through proven change management processes.
Ensure the appropriate structure and talent is in place to meet system quality, safety, and regulatory needs.
Promote evidence-based practices while improving data gathering and benchmarking to create metrics that help the organization provide the highest and safest, quality of care.
Relentlessly focus on safety and quality: champion and lead efforts of safety and quality improvement with the goal of maintaining and achieving national quality ratings.
Develop quality and safety training programs while also setting standards of performance improvement methodologies.
Position Summary Reporting directly to the Chief Physician Executive, the Chief Quality Officer of West Tennessee Healthcare has oversight and responsibility for all quality and patient safety related activities throughout the system. They direct all efforts of performance improvement initiatives to ensure compliance with all regulatory standards through national, state, CMS, Joint Commission, and other agencies. The CQO is integral for further development of analytics, clinical data management, decision support, and the application of evidence-based best practices. They will exert their leadership influence in a manner that permeates the entire organization ensuring that clinical excellence remains a priority for every team member.
Beyond focusing on quality, patient safety, and harm reduction, the CQO will develop and grow strong relationships at all levels of the organization to support, promote, and encourage a culture of quality and safety. They will build and strengthen clinical collaboration across the system in the dynamic and everchanging healthcare environment to ensure effective clinical integration.
Key Responsibilities The CQO will have a broad set of responsibilities, with a focus on the following areas:
Facilitate alignment between improvement initiatives and the organizations strategic plan; direct the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
Responsible for maintaining the facility system-wide quality program; to include data collection, aggregate and analyze data, maintain policies and procedures and report to administrators, Medical Staff, and the Board.
Oversee regulatory interactions: evaluate system-wide programs, policies, and procedures to ensure compliance with applicable federal and state laws and regulations. Oversee onsite evaluation visits and keep abreast of changes that may affect the enterprise.
Develop an understanding of current quality initiatives, data collection, and reporting processes to create, direct, and execute the overarching strategic plan of action in collaboration with clinical and executive leaders with multi-year defined outcomes.
Serve as an internal consultant to administration, staff, and physicians in the areas of regulatory needs, process improvement, performance monitoring, and statistical analysis.
Through dedication to “systemness,” facilitate the synchronization of patient-centric, efficient and effective clinical care across West Tennessee Healthcare.
Support efforts to rationalize clinical resources with an intention to appropriately reduce expenses and enhance revenues through coordinated value enhancement efforts.
Focus on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
Mentor and develop leaders to promote engagement, support, and alignment to meet system-wide initiatives.
Ensure that evidence-based clinical guidelines and practices are developed, communicated, and implemented, and that the impacts of such are measured across the continuum of care.
Facilitate the use of key indicators/metrics and drive the commitment to data driven decision making and optimal clinical performance. Build upon the current quality and safety measures throughout the organization by chasing zero on negative outcomes and using relevant process improvement to elevate quality performance.
Facilitate collaborative communication and the exchange of information, analytics, and dashboards between system physicians and hospital-based executives/physicians.
Organize all Quality Management meetings. Maintain minutes and make recommendations to the committee based on best practices and regulatory standards.
Assess current structure and partner with quality and safety committees. Advise and educate around key strategies and tactics using performance metrics to share progress.
Analyze all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality i.e.: Core Measures, Hospital Acquired Conditions, etc.
Assist in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness and reliability using available information systems data. Where other data is necessary but not readily available, work to design and implement appropriate data collection.
Manage performance improvement projects, flow, and alignment to assure milestones and key performance indicators are met within defined parameters. Document results and submit other documentation as requested.
Conduct internal audits and risk analysis checks. Review, investigate, and analyze incidents for risk and adverse event identification, loss prevention, and claims management purposes including both potential and actual patient injury. Recommend interventions to enhance the safety and well-being of patients, staff, and organization at large.
Complete annual performance evaluations for self and employees as well as implement plans of correction when needed.
Manage a departmental budget; lead cost efficient and effective operations, create a plan of correction for any operating expenses.
Partner with hospital executive, clinical, and facility leadership to drive quality and safety outcomes at the facility level.
Oversee registry and database development.
Establish a culture of quality and safety standards that promote healthcare equity.
Professional Experience/Qualifications The Chief Quality Officer will have a minimum of 10 years of experience in a hospital facility, including at least 5 years of serving in a supervisory or management role is required. Experience leading quality and risk functions is preferred.
Specific experience, skills, and attributes should include:
Successful track record as a leader in clinical performance improvement, change management, quality, and patient safety. Reputation for vigorous leadership and successful track record of effectively driving and supporting clinical quality and safety at all levels in the organization.
Able to collaborate and be a consensus builder who successfully engages with various constituencies. Demonstrates decisiveness and “respectful courage” when gaining consensus amongst a group of individuals.
Possess healthcare industry knowledge with the understanding of the issues facing the delivery of healthcare across the continuum of care services, including population health, analytics, and electronic medical record optimization. Demonstrates an understanding of the business and financial implications of changing care delivery across all care settings.
Able to apply principles of team process and dynamics, employee empowerment strategies, personnel management, and physician relations.
Knowledge of advanced principles, techniques, and theory in quality and patient safety.
Experience leading successful projects and initiatives that have major impact to an organization.
Able to establish, lead, and maintain an effective and results oriented management team.
Knowledge of State, Federal, and JCAHO regulations.
Education and Licensure Operations or Clinical Executive: Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred. CPHQ (Certified Professional in Healthcare Quality), preferred.
The Community Jackson, Tennessee Jackson is located halfway between Memphis and Nashville on Interstate 40, in the heart of the Americana Music Triangle. Jackson is a vibrant city filled with music, great restaurants, numerous recreational activities, and a strong community. The soul of Jackson is downtown where the people are what make downtown the heart of the city. It’s a small community filled with many places to visit and see. Downtown has something to offer for everyone. It’s filled with local art, performances, shops, and places to eat.
Jackson is where country music connected to the blues and the sound of Rock-A-Billy was heard around the world. From the Jackson Symphony to concerts at AMP, from Jackson Theatre Guild productions to Ballet Arts, Jackson celebrates the arts. The Jackson Arts Council works to strengthen the arts in their community. In addition to performances, you’ll find public art installations such as murals, sculptures, and other mediums throughout the city.
Jackson offers numerous sport and recreation opportunities for everyone to enjoy. There are recreational leagues to participate in, tennis courts, hiking and cycling trails, and much more. There are also many places around Jackson where you can enjoy water activities like kayaking. Middle Fork Bottoms is a new park that’s paved with walking trails, has a 10-acre fishing lake, boardwalks, and stunning overlook areas. In addition, the West TN Healthcare Sportsplex offers 17 baseball and softball fields, 20 public parks covering 800 acres, and 2 dog parks.