Director Med Staff Services

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 follow-up) for the following committees:

• 
  Medical Executive Committee

• 
  Credentials Committee

• 
  Leadership Council

• 
  Bylaws Committee (as necessary)

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

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

Manage correspondence between facility and individual medical staff members, not related to credentialing matters.

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

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

Ensure all facility non-privileged practitioner processes are completed 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 de-provisioning of system access to align with a practitioner’s status.

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

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

Coordinate with the facility’s quality department to facilitate focused professional practice evaluation (FPPE), and any related evaluation at the conclusion of FPPE.

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

Coordinate with the facility’s quality department in conducting 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 and quality department 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).

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

Facilitate due process in accordance with the facility’s fair hearing and appeals policy as well as legal and regulatory requirements.

In accordance with Ethics & Compliance Policy EC.023, and in coordination with the facility’s ECO, submit a Reportable Issue report for any instances of a practitioner providing patient care within the facility without a legally required credential (e.g., license, DEA), or while under a Federal or state sanction, or without having current, approved clinical privileges.

Manage and maintain the NPDB account as the Data Bank Administrator.

In collaboration with the facility’s Operation Counsel and appropriate facility leaders, submit reports to the NPDB as required by Federal Law.

Manage and respond to any requests for information made as the result of a NPDB report.

Coordinate the completion of the NPDB’s attestation by the facility’s Attesting Official at the time of renewal of the facility’s registration with the NPDB.

Subscribe to the “NPDB Insights” e-newsletter; review it and communicate any changes in requirements to the appropriate facility executives.

Develop and maintain a policy regarding the management, access to, and distribution of credentialing, privileging, and peer review information, in accordance with confidentiality requirements and record retention policies.

Archive any locally maintained credentialing, privileging or peer review records in accordance with record retention policies.

Respond to external requests for information in accordance with policy.

Attend initial orientation from the CPC and HCA’s Professional Practice Advancement department.

Maintain an acute awareness and accurate interpretation of the HCA Healthcare credentialing policies and procedures.

Read and be familiar with the HCA Healthcare Model Medical Staff Governance Documents (e.g., bylaws, credentials policy and organization manual), the PPE Manuals, and other model medical staff policies, and support the facility’s medical staff in their review and adoption.

Read and be familiar with facility Medical Staff Governance Documents (e.g., bylaws, credentials policy) to understand where they may differ from the HCA Healthcare models.

Support facility adoption of template Medical Staff Services Department policies.

Be familiar with CPC policies as they impact the facility’s MSSD.

Read and act on announcements and alerts from the Division and/or CPC, including:

• 
  Expirable credentials notifications

• 
  Dynamic flag alerts

• 
  Notices of changes or updates to Cactus, or CPC procedures

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

Participate in planning for future medical staff recruitment.

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

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

Facilitate orientation for new medical staff officers and committee members.

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

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

Notify the CPC, Division 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.

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

Verify applicant identity in accordance with MSS-004.

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

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

• 
  CME credits in accordance with medical staff bylaws.

• 
  Volume

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 department chair 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 by maximizing use of iObserver functionality in Cactus, as necessary.

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

In collaboration with Division, 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 MSS-013, as applicable.

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

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 Form (eSAF) Tool to trigger provisioning and/or deprovision 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 action taken against a practitioner’s medical staff membership or clinical privileges, as directed by facility leaders.

Read and act on the weekly information from HCA’s Professional Practice Advancement department (e.g., Answer of the Week, Important Updates, and other announcements).

Participate in monthly “Village” calls.

Facilitate development, implementation and maintenance of standardized delineation of privileges.

Ensure the facility Medical Staff Services operations conform to local, state, and federal governmental regulations as well as HCA Healthcare Policy.

Fosters a culture that inspires commitment to the vision/mission/values of the organization. Ensures employees are recognized, valued, and supported. Develops and implements strategies to elevate employee engagement.

Identifies development opportunities or training needs of individual employees and teams. Provides coaching, feedback, and training to improve performance.

Builds a competitively superior organization through attracting, developing, engaging, and retaining talent. Ensures people with the right skills and motivations are in the right role, at the right time, to meet business needs.

Collaborates with administrative team and physicians to enhance existing services or develop new service offerings.

Identifies opportunities for expansion or development of new services and product lines to promote growth. Identifies stakeholder engagement strategies, technology advances, and other opportunities to drive differentiation and increase volume.

Participates in the annual budget process, including input into department revenue and expense forecasts, staffing, and supply and equipment needs. Monitors department budget performance; identifies trends and evaluates variances in relation to established budget. Develops and implements actions to address performance gaps.

Ensures effective labor management, including position control, scheduling excellence, productivity management, and premium pay utilization. Maintains staffing to ensure appropriate patient care.

Manages operating expenses, including the utilization of supplies and equipment. Identifies cost reduction opportunities and implements actions to achieve savings.