Directs Quality Services, Risk Management, Patient Safety, Wound Care and Infection Control programs for the Hospital and Medical Staff. Directs credentialing activities and the development of the credentialing link to quality improvement activities and physician peer review. Oversees medical departments and committees to assure that objectives are met. Liaison with medical staff, hospital administration and others to assure maintenance and enhancement of effective relationships.
Oversees Medical Staff minutes and quality improvement data / documentation in an effort to limit legal exposures and assure compliance with accrediting bodies.
Controls dessimination of communication between hosptal, medical staff and hospital departments related to medical staff services and quality improvement. Works closely with the medical staff to troubleshoot problems and gather input for improvement. Oversees timely and accurate submission of data for public reporting, i.e.,core measures for TJC, TMF, CMS, TDH, THCIC.