A Checklist for Today’s Chief Medical Officer

October 2019


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In today’s healthcare environment, chief medical officers (CMOs)—the bridge between the clinical and administrative arms of healthcare organizations—are tasked with greater responsibility than ever before. From managing medical staff, to ensuring regulatory and safety standard compliance, to leading the transition to value‑based care, a CMO’s work is seemingly never-ending—and at times overwhelming.

The following checklist can serve as a guide for CMOs on the key issues they should focus on to successfully lead their organization in today’s healthcare environment.

Managing Value-Based Purchasing Goals

Primary Responsibilities:
  • Four Domains
    • Patient Experience
    • Efficiency
    • Clinical Processes of Care
    • Outcomes
  • Hospital Acquired Conditions (HACs)
  • Readmission Reduction
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Key Questions to Ask:
  • Have you looked at the latest preview report for Value-Based Purchasing (VBP) predictions?
  • Have you looked at the status report for HACs?
  • Have you looked at the latest White Cloud data for readmissions? What initiatives do you have in place for reduction?
  • How are your HCAHPS scores?
  • Are you working on any local key quality issues?

Managing Clinical Documentation

Primary Responsibilities:
  • Clinical Documentation Improvement (CDI) Coordination
  • Severity of Illness (SOI)
  • Physician Education
Key Questions to Ask:
  • What is your 3M severity adjusted mortality rate?
  • What is your physician query response rate?
  • Have you had any deaths with SOI 1 or 2?

Managing the Four Disciplines of Execution (4DX)

Primary Responsibilities:
  • Lagging and Designated Leading Indicator Processes
  • LEAN Processes
Key Questions to Ask:
  • Are you meeting weekly on your leading indicators? How are they impacting the lagging indicators?
  • Do you have any LEAN processes in progress? What are they, and what are the outcomes?

Managing the Journey to Becoming a High Reliability Organization (HRO)

Primary Responsibilities:
  • Hardwire Error Prevention Training
  • Report All Serious Safety Events (SSEs) Immediately When They Occur to Quality, Risk Management and Legal Departments
  • Establish Root Cause Analysis Process Within 48 Hours of the Event
  • Operationalize “Safety Coaches” at Your Facility
Key Questions to Ask:
  •    Have you completed the Error Prevention Training for the medical staff?
  •    Are there any SSEs to report? If so, have you initiated a Root Cause Analysis process within 48 hours of the event?
  •    Are you investigating any possible SSEs?
  •    Have you established safety coaches at your facility?

Managing Routine Medical Staff Activities

Primary Responsibilities:
  • Manage the Medical Staff Peer Review (PR) Process
  • Oversee the Medical Staff Credentialing Processes
    • Ongoing Professional Practice Evaluation (OPPE)
    • Focused Professional Practice Evaluation (FPPE)
Key Questions to Ask:
  •    Do you have any outstanding PR issues?
  •    Do you have any outstanding credentialing issues?
  •    Are you performing OPPE every 8 months?

Managing Regulatory Preparedness

Primary Responsibilities:
  • Manage All Insurance Inquiries with the Assistance of Corporate Risk and Quality
  • Report All Regulatory Visits from the Following Bodies Immediately to Your Quality Department
    • The Joint Commission (TJC)
    • The Centers for Medicare & Medicaid Services (CMS)
    • The Department of Health (DOH)
    • The Food and Drug Administration (FDA)
    • The Office of Inspector General (OIG)
    • Other
  • Manage All Surveys and Subsequent Plans of Correction (POCs)
Key Questions to Ask:
  • Are there any outstanding regulatory inquiries from any of the following agencies or organizations?
    • TJC
    • CMS
    • DOH
    • Payers
    • Other
  • Are you expecting any surveys?
  • Are you completing any POCs?

Managing Meetings

Primary Responsibilities:
  • Mandatory Corporate Meetings (i.e., physician leaders or quality council calls)
  • Optional Corporate Meetings (i.e., CNO/CQO or clinical council calls)
  • Facility Meetings
    • Look to your CEO to determine which facility C-Suite and medical staff meetings you should attend
Key Questions to Ask:
  • Were you able to attend all mandatory meetings last month?
  • Were you able to attend any optional meetings last month?
Optional Duties
Primary Responsibilities:
  • Observation vs. Admit Status
  • Denial Management
  • Medical Staff Transition to a New Facility or Transition of a New Facility to the RC Family
Key Questions to Ask:
  • As appropriate