Mgr, Medical Staff Performance Improvement - FT Days

Management 87502 - Performance Improvement Full-Time Days 8 Hour


Under the direction of the Director of Medical Staff Services/PI this position plans and organizes the workflow of the day to day activities of the Medical Staff /PI Department. This position also is responsible for the technical support of the Medical Staff Services/PI Department. This position oversees the utilization and analysis of all data related to the Medical Staff performance improvement processes and collaborates with physician leaders to drive improvement.

Core Competencies

  • Assists with the development of the budget and annual goals for the Medical Staff Services/PI Department. Assists with evaluation of equipment and computer needs.
  • Conducts Employee Performance Appraisals for the Medical Staff PI Coordinators/Analysts.
  • Provides direction to the Medical Staff Coordinators concerning performance improvement activities
  • Ensures appropriate confidentiality measures are implemented to protect information organized and collected by the Medical Staff Services and Performance Improvement Department.
  • Assists with the design and coordination of performance improvement efforts for the departments and committees of the Medical Staff.
  • Prepares reports, analyses, and dashboards utilizing appropriate systems that support the performance of the medical staff.
  • Assumes responsibility for Ongoing Professional Practice Evaluation (OPPE) process and reporting.
  • Supports root cause analysis (RCA) and Kaizens associated with items related to Medical Staff
  • Communicates, delivers presentations, and solicits feedback with all levels of management, hospital staff, medical staff leadership, and key stakeholders regarding the planning and progress of key programmatic and organizational priorities.
  • Works independently or in a group to design and implement processes for assessing patient out comes, utilization trends and other performance improvement activities for the medical staff.
  • Utilizes a variety of clinical data to perform or lead special studies.
  • Assists with issue definition, requirement gathering, analysis design and statistical testing, results interpretation and discussion of findings as related to medical staff performance improvement.
  • Designs, documents, develops, tests, and rolls out clinical and utilization reports using a variety of computing tools (eg, SAS, MS SQL, Excel, Access.) Provides ad-hoc analysis as needed.
  • Provides information for the Medical Staff in the form of reports from analysis of existing database. (Database includes: Medical Record generated indices, Insight Database, CDB, and Medical Staff/Case Review Data.)
  • Identifies and participates in opportunities to optimize/ enhance accuracy and efficiencies in collecting and reporting data internally and externally.
  • Develops effective reporting formats of quality related information to enhance overall communication of quality related information and findings.
  • Manages workload to assure projects are completed within specified time frame.
  • Provides input in the identification of clinical quality improvement opportunities as they relate to the Medical Staff. (This includes comparison of TMMC performance to the recognized standards).
  • Assists medical staff in understanding and meeting TJC, DNV and other regulatory requirements.
  • Monitors the effectiveness of solutions implemented to solve identified problems and provides feedback to Medical Staff departments and committees.
  • Informs supervisor promptly of problems or unusual matters of significance and initiates process improvement action when appropriate and/or suggests alternatives to supervisor for decision.
  • Performs data analysis of Patient Satisfaction Survey reports.
  • Provides the day to day supervision of the Medical Staff Coordinators regarding the peer review process.

Department Specific Competencies


Additional Information
• Bachelor's degree plus three or more years' experience in a hospital or healthcare environment, which includes Medical
; Terminology, HIM Coding practices, statistical analysis, and project management (or) Master's Degree in HCA, MPA, or
; MBA with specialty in healthcare plus one year of hospital or healthcare environment experience.
;• Lean Certification required or achieved within one year of obtaining position.
;• Certification in Health Care Quality required or achieved within one year of obtaining position.


Number of Years ExperienceType of Experience
Additional Information

License / Certification Requirements