Director Med Staff Services

Director Medical Staff Services

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The Director of Medical Staff Services assists with implementation of and compliance with credentialing initiatives/processes. The incumbent is expected to maintain a working knowledge of applicable HCA Healthcare and Parallon Credentialing Processing Center (CPC) policies, accreditation standards and regulations associated with medical staff services, and play a key role in the integration of HCA Clinical Strategies and HCA systems.

Medical Staff Administration

Develop facility credentialing policies in accordance with accreditation/regulatory standards, HCA Healthcare policies, and medical staff bylaws.

Facilitate meetings (develop agendas, maintain meeting minutes, coordinate followup) for the following committees:

a. Medical Executive Committee

b. Credentials Committee

c. Leadership Council

d. Other Medical Staff Committee, Department and Service Meetings as assigned.

Coordinate the work of the Leadership Council in matters related to practitioner health and professional conduct, and support functions for continued monitoring.

Coordinate other facility committees as assigned.

Maintain the official emergency call schedule and records for call compensation payments.

Manage correspondence between facility and individual medical staff members.

Provide support functions to medical staff officers in performance of their duties.

Prepare credentialing reports for medical staff leaders, committees, and the governing body.

Develop, maintain, and distribute medical staff governance documents (i.e. bylaws, rules & regulations, policies) and implement annual review process.

Serve as the primary liaison between the facility, Division Medical Staff Services and the CPC.

Ensure all facility non-privileged practitioner processes in accordance with Ethics & Compliance Policy CSG.QS.002 to include updates to the electronic Security Access Form (eSAF) Tool to trigger provisioning and/or deprovisioning of system access to align with a practitioner's status.

Ensure tokens of appreciation and gifts provided to members of the medical staff are reported to the ECO to log on the Business Courtesy Log, in accordance with Ethics & Compliance Policies LL.022, EC.005, EC.006, and EC.008.

If applicable, Coordinate the collection and handling of medical staff dues and other fees in accordance with Ethics & Compliance Policy TRE.001.

Update Meditech Practitioner Dictionary/Database to be consistent with practitioner data in Cactus.

Participate in planning for future medical staff recruitment.

Develop annual business plan and develop and supervise annual budget if assigned.

Edit and write a medical staff newsletter or maintain the medical staff related section of facility website, or other sources of medical staff news and information.

Maintain and distribute master medical staff calendar of activities.

Manage medical staff hotline.

Medical Staff Education

Facilitate orientation for new medical staff members (in partnership with other key stakeholders to include Director of Advanced Clinical and IT&S personnel).

Facilitate orientation for new officers, committee members and governing body.

Provide education to administrators and department directors regarding CPC operations and MSSD operations, privileging (including temporary and disaster privileging), and non-privileged practitioner credentialing.

Facilitate any continuing medical education (CME) programs offered through the facility.

Accreditation and Regulatory Compliance

Serve as the facility's subject matter expert regarding relevant accreditation and regulatory requirements related to the medical staff.

Notify the CPC, Division MSS and corporate teams of any upcoming or ongoing surveys relative to credentialing, privileging and PPE/peer review activities and functions.

Coordinate accreditation, regulatory, and any internal surveys relative to credentialing, privileging and PPE/peer review activities and functions.

Respond to any reviews accreditation and regulatory compliance citations or deficiencies by developing and implementing corrective action plans.

Facility-based Credentialing Tasks

Apply the credentials evaluation process uniformly to all RFC/applications and RRFC/re-applications to ensure compliance with internal credentialing procedures.

Process each RFC/application and R-RFC/re-application received from the CPC that has a flag in accordance with CPC-32 and MSS-002 policy.

Verify applicant identity in accordance with MSS-004.

Forward any updated information received from a practitioner to the Division MSS/CPC in a timely manner.

Compile and analyze any available internal data and information for an assessment of qualifications and competencies for each R-RFC/re-application.

i. CME credits in accordance with medical staff bylaws.

ii. Volume

iii. Focused or ongoing professional practice evaluations (FPPE/OPPE), performance improvement, utilization patterns, peer review, or other performance information.

Facilitate review, assessment, and authenticated documentation of an evaluation of each application and request for clinical privileges by the section chief / department chairman as required.

Facilitate review, assessment and recommendations for each application and request for clinical privileges by the Credentials Committee and the Medical Executive Committee.

Utilize "paper-lite" procedures to facilitate medical staff reviews/maximize use of iObserver functionality in Cactus.

Summarize and prepare credentialing information, including information about flagged concerns, for the board's review and decisions.

Actively manage each practitioner's expiring credentials in accordance with CPC-36 and MSS-003.

Update Cactus and MEDITECH system's Practitioner Dictionary/Database to reflect all board actions on a practitioner's RFC, R-RFC, including resignations, terminations, LOAs, denials, terminations, or withdrawals in accordance with CPC-28 and MSS013.

Manage and archive files according to HCA Healthcare and facility procedures and accreditation/regulatory standards.

Privileging

Facilitate development of eligibility criteria for each clinical privilege or grouping of clinical privileges that require the same qualifications and competencies.

Facilitate the review of requests for clinical privileges using the approved eligibility criteria.

Assess the applicability and appropriateness of clinical privileges for each specialty through periodic review.

Maintain all up-to-date privilege content within the Visual Cactus system and MEDITECH Practitioner Dictionary/Database to reflect all board actions including approvals, denials or terminations in accordance with CPC-28 and MSS-013.

Update electronic Security Access From (eSAF) Tool to trigger provisioning and/or deprovisioning of system access to align with practitioner's membership status and/or clinical privileges.

Coordinate access by authorized facility staff to credentialing information as needed through iPrivileges or iPharmacy portal.

Facilitate any required regulatory agency reporting of adverse actions taken against a practitioner's medical staff membership or clinical privileges, as directed by facility leaders.

Performance Improvement/Peer Review/Patient Safety

Coordinate with the facility's quality department to facilitate focused professional practice evaluation (FPPE), and any related evaluation at the conclusion of FPPE or a period of provisional status.

Coordinate with the facility's quality department to facilitate ongoing professional practice evaluation (OPPE).

Coordinate with facility leadership in the conduct of internal and external peer reviews.

Complete a summary of FPPE, OPPE, and peer review results for evaluation by medical staff leaders as part of the R-RFC process as noted in 4e above, and ongoing as required by policy.

In collaboration with the CPC, identify critical MSSD performance benchmarks, measure performance, and take action to improve when performance is not as desired or expected.

Coordinate with the facility's Patient Safety Officer in the medical staff review of occurrence reports, patient complaints, close call data, and SPAE reports.

Coordinate with the facility's Patient Safety Officer regarding medical staff participation in any activities performed as part of the HCA Healthcare Patient Safety Organization (PSO), including the appropriate handling of Patient Safety Work Product (PSWP).

Risk Management

Coordinate with the risk manager to review and evaluate an applicant's claims history and National Practitioner Data Bank or other reports regarding final settlements.

Ensure timely and proper notification of the risk manager regarding possible malpractice or other liability concerns.

Coordinate all medical staff disciplinary actions (e.g., formal investigations, professional review actions).

Facilitate due process in accordance with the facility