Exeter Hospital

Req#13712 Internal Only

Req#: 13712
Full Time,Day Shift Monday – Friday, 8a – 5p

The Chief Medical Officer (CMO), a member of the senior leadership team, is responsible for the development, implementation and monitoring of standards of clinical practice, and for the overall integration, coordination and quality of clinical care provided by the medical staff of Exeter Hospital. The CMO is responsible for the overall medical and administrative affairs related to health care delivery and medical staff management of patient care while providing a visible, institutional commitment to quality at Exeter Hospital. The position fosters and maintains the partnership between the Hospital and its medical staff, aligning the quality processes and outcomes, assuring appropriate utilization of resources, championing a culture of safety, and supporting care standards to elevate the level of quality and efficiency.

Only considering internal applicants at this time.


Educational Requirements/Credentials: 

Medical degree, board certified in an appropriate medical specialty.
Licensed to practice, in good standing (or eligible for license) in the state of New Hampshire

Experience Requirements:

  • A minimum of 7 -10 years of professional clinical practice.
  • Documented leadership in areas of health care quality, including involvement in successful DNV/CMS surveys
  • Knowledge of external regulatory and reporting requirements and payor initiatives impacting on quality assessment programs.
  • Demonstrated experience in medical staff and administrative affairs as evidenced by serving on an organization's medical/executive committee or quality committee.
  • Credentialed (or eligible to be credentialed) by Exeter Hospital
  • Demonstrated commitment to high clinical standards and concern for patients both at the bedside and in the community.
  • Must possess a proven patient-centered approach to care with the desire to take that commitment from clinical practice to organizational leadership.

1.  The CMO is responsible for the oversight and direction of the Department of Quality and Patient Safety, the medical staff office and affairs.
2.  The CMO collaborates with the Chiefs of Service to assure congruence with the overall direction and standards of medical professional leadership within the organization by working collaboratively with other senior leaders and medical staff leaders to assure performance of department directors/managers for functional clinical areas.
3.  Develop and coordinate implementation of an annual performance improvement/patient care assessment plan and initiatives that respond to, though not limited to:

  • standards of practice
  • community health needs assessment.
  • external regulatory and reporting requirements
  • demand for clinical services
  • an approved strategic plan.
  • assure appropriate management and utilization of resources
  • work collaboratively to optimize adoption of new methods and technologies implemented by the hospital.

4.  Responsible for the overall medical/administrative affairs related to health care delivery and medical staff management of patient care. 
5.  Devise and implement quality improvement plans through the existing organizational structure and ensure that the standards, processes and outcomes of these efforts are aligned with those of BILH.
6.  In collaboration with the BILH system, establish quality processes and outcomes at Exeter Hospital by developing and incorporating standards and programs in conjunction with the BILH system, to ensure that the standards of practice/clinical care are integrated/aligned and consistently met.
7.  Provide oversight for the development and implementation of methods to measure and track quality metrics to compare results against internal and external norms, benchmarks, and standards of excellence.
8.  Establish monitoring and evaluation related to implementation of required quality metric performance improvement plans.
9.  Work collaboratively with employed, contracted, and independent physicians to establish qualifications for and monitor appointments/re-appointments of all clinical staff; establish and monitor standards and outcomes of clinical practice; participate in the search and make recommendations regarding appointments of Chiefs of Service.
10.  Provide direct leadership of the Hospital's quality and outcome improvement efforts.
11.  Partners with medical staff leadership in the development, coordination, implementation, and evaluation of annual performance improvement plans and initiatives for the service departments that reflect:

  • current evidence-based practices.
  • community health assessment and demand for clinical services
  • regulatory and reporting requirements.
  • organizational strategic plan and patient care assessment plan and in the enforcement of Hospital and Medical Staff Bylaws, Rules, Regulations, Policies and Procedures.

12.  Serves as the Hospital's administrative representative, lead, resource, and/or contributing member of the Medical Staff Assessment Committee, Quality and Patient Safety Committee, Patient Experience/Quality Assessment Committee, Credentials Committee, Medical Executive Committee, Clinical Practice Committee, and other committees as assigned or necessary to fulfill the role or as requested by the President.
13.  Consults with the Medical Staff Service Chiefs on the development and implementation of service programs that encompass:

  • Medical clinical care measures of performance in accordance with medical specialty organizations' standards, internal and external benchmarks, and regulatory requirements/expectations
  • Interactive and active mechanisms to monitor measures of performance
  • Methods to determine effectiveness of measures and outcomes of care
  • Methods for revision and advancement of medical practices reflective of performance improvement initiatives
  • The development, implementation, and provision of guidance on medical policies and procedures.


14.  Performs an active role in promoting physician involvement and integration in hospital wide and where
appropriate system wide programs, committees and new initiatives.

15.  Serves on committees, task forces or other groups, internal or external to the organization, as required from time to time and as designated by the President.
16.  Maintain content awareness of regulations and standards affecting assigned areas of responsibility through ongoing professional development. Interprets new regulations and requirements and oversees their implementation.
17.  Attends seminars, workshops, and maintains professional affiliations to keep abreast of latest trends in field of expertise especially related to health care quality, regulatory affairs, organizational behavior and leadership.
18.  Performs all duties in accordance with safety and other laws, rules and regulations as set forth by appropriate regulatory and government agencies and in accordance with established department and hospital policies and procedures, and in accordance with the Hospital's Code of Conduct and employee standards of performance.
19.  May be required to perform similar or related duties as may be necessary on a temporary or an emergency basis.


A Physical Abilities Job Description is a component of this Job Description.

The above statements are intended to describe the general nature and level of work to be performed. They are not to be construed as an exhaustive list of all responsibilities and skills required of personnel so classified.


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