Assistant Director, Physician Excellence

Position Summary The Assistant Director of Physician Excellence is responsible for supporting the direction and oversight of Medical Staff quality review initiatives, with a focus on enhancing Practitioner performance and patient care outcomes. This role involves the development, implementation, and management of ongoing and focused professional practice evaluations (OPPE/FPPE) and guidance and support of the Medical Staff Peer Review process. The Assistant Director ensures work products are streamlined and in compliance with Medical Staff Organizational Documents, Hospital policies and Joint Commission accreditation standards. The Assistant Director collaborates closely with Medical Staff leadership, quality teams, and other stakeholders to identify areas for improvement, facilitate continuous quality improvement processes, and promote a culture of clinical excellence across the organization. Duties & Responsibilities • Coordinates the execution of Professional Practice Evaluation (PPE) and related quality initiatives at the University of Illinois Hospital and Clinics and in accordance with Joint Commission, CMS and other regulatory agency requirements. • Partners in the management and development and review of PPE guidelines, processes and policies with the Senior Director, MSS and Medical Staff Leaders as appropriate. • Directs the selection, validation and approval of OPPE Metrics for each clinical department; including annual review of metrics to ensure metrics remain in accordance with the quality and safety goals of the organization • Directs the validation of monthly OPPE metric data extracted by the Physician Excellence Data Analyst • Direct, produce and record monthly OPPE metrics dashboards for each clinical Department as well as individual Practitioner dashboards for the defined OPPE cycle • Collaboration and execution of track/trend data for OPPE metric non-compliance by Department and Practitioner; recommend and advance Practitioner into FPPE cycle as appropriate. Monitor all Practitioner FPPE (for OPPE metric non-compliance) and provide report at defined intervals • Collaboration and execution of FPPE for Practitioners granted new and/or additional privileges, recommend and advance Practitioner into OPPE cycle as appropriate. Monitor all Practitioner FPPE (for new and/or additional privileges) and provide report at defined intervals • Contributes to the oversight of FPPE Improvement Plans at the request of the Peer and Exemplary Review Committee OR other Committees of the Medical Staff, the Medical Staff Officers and/or CMO as part of Collegial Intervention efforts. . Monitor all Practitioner FPPE (for Improvement Plans) and provide report at defined intervals • Ensure all PPE reports are reviewed by the Clinical Chief of Service and Practitioner as appropriate and considered at the time of reappointment/renewal of credentialing and/or privileging. • Develop and maintain a master schedule of OPPE and FPPE Cycles/Plans • Develop and prepare FPPE and OPPE summary reports for discussion with Medical Staff and CMO Leadership, and for presentation at defined Committees of the Medical Staff • Oversee software functionality which supports both the Peer Review and Professional Practice Process • Support and assist the leadership of Credentials Committee, Medical Staff Executive Committee and the Peer and Exemplary Review Committee as needed and as it relates to Medical Staff quality. • Participate as a key leader in Joint Commission accreditation site visits as requested by the Senior Director, MSS and Deputy Director, PE • Direct oversight of OPPE and FPPE data integrity to ensure accurate documentation and compliance • Direct Supervision of staff in the Quality Specialist Series to ensure successful execution of assigned job functions. • Direct Supervision of Nurse Case Reviewers in support of Medical Staff Peer Review activity. • Indirect Supervisio