And Prep for Your Interview

This week, John describes what a great hospital quality medical director needs to know to succeed. By understanding and implementing these concepts, the medical director will be able to lead a strong QI program.

A hospital's quality improvement program is designed to ensure that medical care is undeniably effective, evidence-based, timely and error-free. The field has exploded over the past 30 years, with an increasing emphasis on measuring and reporting outcomes of care.

Though it’s unlikely anyone is building a quality program from scratch, the information presented in this episode is useful for anyone from a part-time hospital quality medical director to a full-time chief quality officer. It will help you to improve your hospital's quality and safety program. And it may help you prepare for an interview for a medical director or chief quality officer position.

Our Sponsor

We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country, with over 650 graduates. And, unlike other programs, which typically run 1 – 1/2 to 2 years, this program only takes a year to complete. Recently, Economist Magazine ranked the business school #1 in the world for the Most Relevant Executive MBA.

While in the program, you'll participate in a company project, thereby contributing to your organization. As a result, University of Tennessee PEMBA students bring exceptional value to their organizations.

Graduates have taken leadership positions at major healthcare organizations. And they've become entrepreneurs and business owners.

By joining the University of Tennessee physician executive MBA, you will develop the business and management skills needed to advance your career. To find out more, contact Dr. Kate Atchley’s office by calling (865) 974-6526 or go to

Culture and Credentialing

The foundation of a great hospital quality program is a culture that values quality and safety. The mission of the organization must include a commitment to patient care that is based on superior quality and patient safety. It’s vital that the culture values teamwork and effective communication.

The underpinning of any good program is to start with a culture of quality and safety.


The ability to measure outcomes is the cornerstone of a quality improvement and patient safety program. The tools used to measure outcomes must use a risk-adjustment methodology in which physicians have confidence.

There are numerous systems  available to extract the data needed to provide clinical quality and safety reporting. Becoming an expert in the measurement tools will make you an invaluable asset to your organization.

Leadership and Structure

Leadership of the QI and PS program is also extremely important. Each hospital must have a knowledgeable clinical expert to lead the department or division. Physicians are best able to understand the impact of quality on the care of our patients. We can help by serving on and leading committees, and by serving as hospital quality medical director or chief medical officer.

Implementation of a great QI program depends on an organizational structure that includes a mastery of QI concepts at each level, from CQO to Pharmacy Director, Quality Improvement Director and Health Information Management Director, to Quality Nurses, Clinical Documentation Improvement Specialists, Infection Preventionists,  and Utilization Management Advisors.

Various command layers are responsible for implementing the QI and PS program. The Board of Directors, CEO, CMO, Quality Improvement Committee, Pharmacy Committee, Safety Committee, and specific issue-related subcommittees such as Length of Stay Committee, and Root Cause Analysis teams comprise this structure. And it needs physicians in management positions such as the hospital quality medical director and chief quality officer coordinating and/or running some of these committees

A policy that is integral to the QI/PS Plan is a Code of Conduct that helps to ensure clear, timely communication. Everyone in the organization must show their commitment to follow the Code, and there must be a way to track compliance and address deviations from the policy

Other Issues

Lastly, there are ongoing activities that contribute to a competent hospital quality program. Peer review continues to be used selectively. And cultural surveys can help promote a culture of quality and safety.

If I’ve piqued your interest, I encourage you to learn more about pursuing a job as a hospital quality medical director. It is a great field for physicians . 

Links for Today's Episode

Nonclinical Career Academy Membership Program is Now Live!

I've created 12 courses and placed them all in an exclusive, low cost membership program. The program provides an introduction to dozens of nontraditional careers, with in-depth lessons on several of them. It even includes my full MSL Course that alone sells for $397.00. And I'll add more content devoted to one of these topics each and every month:

  • Nontraditional Careers: Locum tenens, Telemedicine, Cash-only Practice
  • Hospital and Health System Jobs
  • Pharma Careers
  • Home-based jobs
  • Preparing for an interview, and writing a resume
  • And more…

Thanks to our sponsor…

Thanks to the UT Physician Executive MBA program for sponsoring the show. It’s an outstanding, highly rated, MBA program designed for working physicians. It might be just what you need to prepare for that joyful, well-paying career. You can find out more at

If you enjoyed today’s episode, share it on Twitter and Facebook, and leave a review on iTunes.

Podcast Editing & Production Services are provided by Oscar Hamilton


The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life or business. 

Many of the links that I refer you to, and that you’ll find in the show notes, are affiliate links. That means that I receive a payment from the seller if you purchase the affiliate item using my link. Doing so has no effect on the price you are charged. And I only promote products and services that I believe are of high quality and will be useful to you, that I have personally used or am very familiar with.

The information presented on this blog and related podcast is for entertainment and/or informational purposes only. It should not be construed as medical, legal, tax, or emotional advice. If you take action on the information provided on the blog or podcast, it is at your own risk. Always consult an attorney, accountant, career counsellor, or other professional before making any major decisions about your career.