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The Manager of Medical Affairs is a leader in the areas of Patient Safety and Peer Review, both of which are under Medical Affairs.  The manager supports the Associate Directors in both areas and is responsible for leading initiatives to enhance patient safety/peer review and quality of care in a healthcare organization.  This position oversees processes related to incident reporting, root cause analysis, and peer reviews to ensure compliance with regulatory standards and the implementation of best practices.  The role involves close collaboration with many leaders across the organization within medical staff, academics, nursing, and operations to ultimately drive top notch clinical care that is consistent with evidenced based practice as well as drive a culture of safety and continuous improvement.

Primary Duties and Responsibilities

In collaboration with Associate Directors of Patient Safety and Peer Review, provides leadership, guidance, and direction for day-to-day operations and activities, including the authority to make independent decisions regarding operations, administration, and governance. Serves as a resource to hospital and Medical Staff leadership regarding the Patient Safety and the Peer Review processes.  Provides consultation to medical staff, senior and service line leadership to incorporate concepts of safety and standards of care into daily work.

Interfaces with internal and external key stakeholders including other departments, leaders across the organization, and representatives from external agencies/organizations to provide guidance, resolve issues, and/or implement processes and/or solutions 

Evaluates the performance of the department operations, including quality assurance and trends. Makes recommendations to leadership and/or implements operational changes based on findings. Reviews data and/or summary findings with participants, stakeholders, leadership, and/or cross-functional teams.

Identifies opportunities for process improvements and introduction of best practices within the department function. Participates in organizational process and/or efficiency initiatives as applicable and related to areas of expertise

Drives change by providing centralized development, implementation, and oversight of programs and initiatives designed to improve and support relevant programs. 

Assesses communication and training needs, develops and implements any applicable communication, education, training, on-boarding and/or mentorship within the department. Provides regular communication to stakeholder departments and leaders across the organization. May work with cross-functional teams across multiple departments to develop communication and training materials

Maintains data system integrity and ensures quality assurance measures are followed based on departmental standard operating procedures. May provide ad hoc reporting to support recommendations observed through trend analysis for future planning and enhancements.

Monitors department programs to ensure appropriate governance and program compliance with local, state, and federal laws; accreditation, professional and regulatory agency standards, and licensure requirements.  Maintains staff and program compliance with organizational policies and procedures.

Demonstrates initiative, resourcefulness, and problem-solving skills in applying a detailed knowledge of the responsibilities, functions, and underlying management structure of the department and of the larger Health System in organizing and prioritizing work, establishing procedures and systems, and ensuring the orderly and timely flow of operations.

Department specific duties

Incident Reporting Oversight:

• Develop, implement, and manage systems for reporting and analyzing patient safety events.
• Monitor trends and identify patterns in incidents to proactively address safety concerns.

Root Cause Analysis (RCA):

• Leads RCA teams to investigate sentinel events, near-misses, and adverse events.
• Develop actionable recommendations and oversee the implementation of corrective measures.

Policy Development and Training:

• Establish patient safety policies, protocols, and procedures.
• Provide education and training to staff on safety initiatives and best practices.

Performance Metrics:

• Track and report safety performance indicators to leadership.
• Collaborate with departments to meet safety-related goals and benchmarks.

Coordination of Peer Reviews:

• Manage the peer review process to assess clinical performance and outcomes.
• Ensure unbiased and confidential evaluations of provider practices.

Compliance and Documentation:

• Maintain accurate documentation of peer review activities in accordance with regulatory requirements and organizational policies.
• Ensure compliance with state and federal healthcare regulations.

Feedback and Improvement:

• Provide constructive feedback to healthcare providers based on peer review outcomes.
• Collaborate with medical staff to address areas needing improvement
• Provides timely peer review requests if asked from the Office of the CMO and maintains confidentiality of all functions of peer review.

Education:

• Bachelor’s degree in Healthcare, Management, Business or related field required

Experience and Skills:

• 3 years of healthcare quality management/performance improvement, program management, or related experience required
• 2 years of experience in a hospital or healthcare-related environment required

Physical Demands: 

Standing, Walking, Sitting, Lifting 50 lbs. Carrying 50 lbs. Pushing  50 lbs. Pulling 50 lbs. Reaching, Handling, Grasping, Feeling, Talking,  Hearing, Repetitive Motions, Eye/Hand/Foot