Job Description: DIRECTOR PROFESSIONAL PRACTICE EXCELLENCE at UNM Hospital

Department: Quality Outcomes

FTE: 1.00
Full Time
Shift: Days

Position Summary:
Directs and coordinates activities and staff to support Medical Staff Peer Review to further the culture of safety through a non-punitive approach to the evaluation of practitioner performance. Works in close collaboration with the Chief of Staff, Professional Practice Committee (PPC) Chair and the Quality Department to provide accurate clinical summaries and trended data to inform Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Responsible for maintaining and securing peer review records, data and files. Ensure adherence to Hospital and Departmental Policies and Procedures. No patient care assignment.

Detailed responsibilities:
* LEADERSHIP - Plan, direct and manage Professional Practice Excellence Team (PET) staff, programs and activities; develop efficient organizational structure, select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
* DIRECT - Directs and manages the peer review process as outlined by the UNM Medical Staff peer review policies and ensures compliance with peer review process consistent with federal and state law, Medical Staff and hospital confidentiality policies
* STRATEGIC INITIATIVES -Assists and provides support with initiatives to achieve annual strategic goals through sharing of data, teaching of quality improvement principles, and process improvement tools
* COLLABORATION - Maintains a close working relationship with UNM Hospitals PPC Chairperson, the Chief of Staff and the Chief Quality Officer. Coordinates activities with all hospital departments involved in data collection and interfaces with Clinical Affairs Staff
* TRAINING - Plans for and provides training for Professional Practice Excellence Team staff as well as stakeholders
* DATA – Oversees and secures the collection of case review data as prescribed by policy for aggregation, analysis and presentation; create charts and graphs to facilitate the communication of data and trends
* REVIEW - Ensures the identification of cases meeting criteria for clinical review from various data sources and through informal reporting; securely maintains evaluation data, reports and minutes of the PPC
* POLICIES - Recommends policy or process revision in accordance with regulatory requirements
* DEVELOPMENT - Maintains current knowledge of CMS and TJC standards as well as UNM Hospital Medical Staff Bylaws and Rules & Regulations in addition to relevant clinical indicators and patient safety metrics
* ANALYSIS- Analyze preliminary findings of review using indicators and screening criteria approved by the Medical Executive Committee

Qualifications

Education:
Essential:
* Bachelor's Degree
Nonessential:
* Master's Degree
Education specialization:
Essential:
* BSN or MSN
Nonessential:
* Nursing

Experience:
Essential:
3 years directly related experience

Nonessential:
No preferred experience

Credentials:
Essential:
* RN in NM or as allowed by reciprocal agreement by NM

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* Subject to an annual contract and performance appraisal