Summary:Administers system-wide compliance programs by implementing compliance systems and processes designed to ensure compliance with applicable laws and regulations as well as internal policies and procedures. In conjunction with MLH leadership, develops the system strategies and direction of medical staff focused performance assessment and improvement, and credentialing at MLH. Responsibilities include all aspects of quality, performance improvement and medical staff credentialing including operational support, quality planning and quality monitoring. Utilizes statistical tools, benchmarking resources, performance measurement, quality management and other resources to determine trends, identify opportunities for improvement and lead change of medical staff quality and credentialing within MLH. Leads improvement of clinical processes that depend primarily on LIP. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Education/Training promotes cooperation among individuals and groups. Develops and implements processes through orientation, training and education to ensure that the competence of all staff members is assessed, maintained, improved and demonstrated throughout their employment.Develops MLH staff through orientation, training, and education in principles of process improvement. Promotes, maintains, demonstrates and communicates the value of self-development and enhancement of the professional competency of staff through quality improvement activities and other educational opportunities. Supervision Provided by this Position:Oversees the Director, Medical Staff Services, Quality Improvement Specialists, Manager, Physician Quality, Physician Quality coordinator, and additional support staff.Active role in Administrative, Board and Medical Staff committee leadership throughout Methodist Healthcare related to Physician Quality and Performance Improvement.
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