POSITION TITLE: DIRECTOR - PROFESSIONAL PRACTICE EVALUATION
DEPARTMENT: Legal Department
SUPERVISOR'S TITLE: Senior Counsel
TITLES SUPERVISED: N/A
TOTAL NUMBER OF FTE's DIRECTLY SUPERVISED: 2-3
TOTAL NUMBER OF FTE's INDIRECTLY SUPERVISED: 0
PURPOSE OF POSITION: To direct and manage the support for and facilitate the Medical Staff Peer Review processes to measure, assess and improve provider clinical performance in a Medical Center dedicated to the care of infants, children, and adolescents. In this role the Director assists in supporting the quality, safety and service initiatives and goals of the Medical Center using Continuous Quality Improvement methodology in managing data collection, analysis and reporting outcomes.
Support all functions of the Professional Practice Evaluation Committee (PPEC) and facilitate the successful accomplishment of its responsibilities. Work directly with the Chairs of the PPEC and Leadership Council to plan, develop, and coordinate the work of the Professional Practice Evaluation (PPE) staff. Report on and maintain all PPE review records and documents. Coordinate PPE case investigations (internal and external) by compiling appropriate medical records, review materials, communicating directly with medical staff and Physician Advisors regarding process and necessary requirements, follow-up and compilation of results, preparation for committee presentation, negotiating with external peer review companies for cases determined to need to be reviewed outside of this facility.
Develop and implement procedures to maintain strict confidentiality of all PPE information.
·Outcomes and Interventions
Work with Division Directors and Chair(s) of PPEC to identify adverse outcomes, clinical occurrences, or complications that will trigger a focused PPE. Review cases identified via triggers and engage with identified practitioners to obtain meaningful input into the review of the care provided. Work with Division Directors and Chair(s) of PPEC to implement appropriate interventions to address any professional competence or conduct concerns identified during this process.
·Reporting and Improvements
Support Department in-Chiefs, Division Directors, and other medical staff leaders in addressing professional competency and conduct development opportunities. Track, trend and monitor provider performance concerns and provide reports on data upon request. Develop performance monitoring plans for providers with trends, collaborate with medical staff leaders to provide coaching, mentoring or counseling for educational opportunities or opportunities for improvement noted during the ongoing PPE process at the division level. Ensure division level peer review is reported to the PPEC on a regular basis for oversight. Ensure that all PPE review data is entered into the appropriate database and work in collaboration with medical staff services to ensure that this data is reported at the time of the provider's OPPE review and reappointment.
·Quality and Grievance Committees
Ongoing provider monitoring/other duties: Cross train with Medical Staff Coordinator to support the Medical Staff office. Work closely with the Quality team and sit on quality and grievance committees to ensure facilitation of any referrals to the medical staff related to complaints/grievances involving members of the medical staff. Support all functions of the Medical Staff as needed upon request.
Skills & Competencies
Strong verbal, written, interpersonal and telephone communication skills. Clearly and accurately conveys complex (potentially sensitive or controversial) information, facilitation skills, ability to provide presentations and education.
Ability to develop, implement and manage projects; knowledge of the principles and concepts of project management including proficiency with relevant project management tools.
Taking responsibility for guiding others' actions and providing direction to a group; stepping forward to take the lead in addressing difficult issues and making tough judgment calls.
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself.
Knowledge of hospital structure and functions.
Ability to independently work through details of a problem to reach a positive solution.
Using inductive and deductive reasoning to formulate general rules or principles and apply them to work; identifying flaws in logical reasoning; understanding complex conceptual relationships; accurately detecting underlying themes or patterns in data.
Work independently, prioritize, self-direction, and set independent goals.
Demonstrate accuracy and attention to detail.
·Bachelor's degree, BSN or other clinical professional degree i.e. OT, PT, PharmD
·4 years healthcare experience in hospital setting
·Current RN or appropriate clinical license
·3 years of quality or patient safety experience Preferred:
·Pediatric healthcare experience
·National Quality Improvement Certification/CPHQ