This leadership position is accountable for the medical-administrative aspects of the medical staff organization; serves as an essential link between senior management and the medical staff to promote and enhance good communications and a positive working relationship. Responsible for establishing, contributing to and maintaining continuity in the planning, development and implementation of standards applicable to the medical staff members relating to credentialing, quality, continuing medical education, medical library and administrative functions. Responsible for medical staff preparation, documentation, and organization and follow-up involved in maintaining hospital accreditation and licensure with the JCAHO and Department of Health Services.
Education or Formal Training
Bachelor’s degree preferred.
Knowledge, Skill and Ability
Effective organizational and personal communication skills including written, verbal, attitudinal and persuasion skills. Functions independently with initiative, creativity and effective analytical problem solving. Uses tact, discretion and objectivity in dealing with confidential and highly emotional situations. Is flexible, detailed orientated and patient. Demonstrates capacity for motivating, facilitating, developing and leading people. Ability to work under pressure with perseverance and fortitude.
Minimum of five years management experience in health care related area. Knowledge of medico-legal issues and regulatory agency requirement and standards.
Directs the medical staff department in the areas of medical staff organization, credentialing, physician quality management, continuing medical education, the medical library and meeting all JCAHO standards.
Administers the credentialing process; new applicant, initial appointment, provisional reviews, appointments and special requests.
Accountable for applicable preparation, organization and follow-up necessary to assure maintenance of the hospital accreditation and licensure.
Assures confidentiality of medical staff activities as they relate to peer review, quality assurance and medico-legal issues.
Educate and direct medical staff officers, committee chairmen and members, other healthcare professionals, and the MSD staff in the development of mechanisms to assess physician performance, identify potential risks and take disciplinary action when appropriate.
Facilitates communication to assure maintenance and enhancement of effective relationships between the medical staff, administration, and ancillary department in matters pertaining to the medical staff.
Oversees case reviews in conjunction with the BCH Risk manager; assists in medical staff research as needed for legal actions or potential legal actions against BCH and/or its physicians.
Assists in sentinel event reviews in conjunctions with the Risk Manager.
Plan and implement schedule for medical staff department and committee meetings; including staffing and continuity of topics, materials, notices, documentation and follow-up.
Administrative responsibility for the medical staff department. Includes employee selection, education, recognition, counseling, evaluation, disciplinary action and termination.
Fiscal responsibility for medical staff department; includes hospital cost center budget plus independent budgets for medical staff organization.
Guides the medical staff in adherence to Joint Commission requirement and prepares reports to satisfy these requirements resulting in medical staff compliance to standards.
Monitors the medical staff action for adherence to medical staff bylaws, applicable law, state and federal regulations, and Joint Commission requirements reporting noncompliance issues to the President of the Medical Staff and BCH President.
Facilitates communication between hospital, medical staff leadership and hospital department and medical staff members as directed.
Prepares reports to the governing board on medical staff recommendations.
Directs the monitoring and education of all medical staff departments in quality improvement requirements as demonstrated by regular reporting of compliant activities.
Monitors reports and minutes of all hospital department and medical staff committees and department to assure adequate activity and documentation of activities with monthly reports to the Medical Executive Committee.
Collaborate with administration and/or department directors, medical staff and the hospital quality management committee in problem identification and assessment, problem resolution and resolution follow-up related to patient care and policy and procedure development.
Oversee completion of annual evaluation of medical staff quality management plan/programs and revisions for the medical staff plan.
Responsible for assisting medical staff to formulate annual quality report to the Medical Executive Committee and Governing Board.
Participated in strategic planning process of the medical staff as requested by administration.
Oversees maintenance of accreditation standards for CME.
Identifies and meets medical staff education needs according to established policies, standards, and new issues.
Acts as liaison with medical staff as requested.
Employees are expected to comply with all regulatory requirements, including Joint Commission Standards.
Is familiar with organization, department and job specific environment of care areas, including life safety, utilities management, hazardous materials communications, emergency preparedness, infection control and equipment failure.
Adheres to Standard Precautions as appropriate. The use of protective barriers as appropriate; gloves, masks, gowns, pocket masks, safety glasses and the handling and disposing of infectious waste appropriately. Hand washing as appropriate.
Performs other duties as requested within the scope of the medical staff department functions and responsibilities.
All employees are expected to remain flexible to meet the needs of the hospital, which may include floating to other departments to assist as the patient needs fluctuate.
WORKING ENVIRONMENT/PHYSICAL ACTIVITIES
Must be able to commute between Broadway, Foothills and Mapleton campuses, attend meetings (including transport of heavy files, books, etc.).
Relates closely to staff within department, medical staff, auditors, hospital administrators, governing board and department directors, hospital staff and outside agencies. Reports to CEO.
Boulder Community Health is a not-for-profit, integrated regional health system with facilities throughout Boulder and the surrounding areas. Our mission is to provide our community with the highest value healthcare in an innovative, patient-centric environment. Our vision: We are partnering to create and care for the healthiest community in the nation.
BCH is known across Colorado for its clin...ical excellence in heart care, orthopedics, cancer care, surgery, primary care, emergency and trauma, urgent care, stroke care and neurology. Some 540 physicians in 54 medical specialties have privileges at BCH.