PRIMARY DUTIES AND RESPONSIBILITIES

Clinical Practice

1. Defines clinical processes based upon evidence based practice guidelines and regulatory standards. Provides oversight for clinical processes and expectations to promote consistent care throughout the system.
2. Collaborates with clinical and operational leadership to identify potential improvement in clinical processes and education and training needs. Provides leadership in facilitating planning for implementation. 
3. Serves as an internal consultant to leadership within the organization and physicians and is a resource for complex patient care situations and process improvements.
4. Provides oversight on the development and evaluation of clinical policies and procedures, clinical practice guidelines, guideline orders, and standards of care. Ensures consistency of clinical guideline documents and policies with recognized regulatory and clinical specialty guidelines

Quality

1. Provides oversight for monitoring and analyzing external clinical quality measures in Women’s Services. Assumes responsibility for defining measurable clinical improvements that support the Patient Care Division in collaboration with clinical and operational leadership and based upon internal and external benchmark data. 
2. Supports clinical and operational leadership in obtaining external recognition of clinical quality (i.e., Joint Commission maternal level of care verification, AAP level of care verification, certifications, and other distinctions).
3. Collaborates with clinical and operational leadership to resolve variances that impact clinical quality measures and outcomes.
4. Provides oversight for root cause analysis processes for obstetric and gynecologic patients throughout the system. Identifies practice patterns and trends, policy variances, and facilitates implementation of corrective actions.

Medical Staff

1.  Provides oversight for the interdisciplinary development of evidence-based clinical practice guidelines and participates in related committees.
2.  Provides oversight for physician clinical quality measures in Women’s Services. Assumes responsibility for defining measureable clinical improvements in collaboration with physician leadership, Quality Improvement, and others involved in physician contract development and monitoring.
3.  Conducts clinical needs assessment for programs and medical services provided by physicians.

Planning and Marketing

1.  Participates in the planning of the Women’s Services Strategic Plan
2.  Provides input into marketing initiates that promote women’s health care
3.  Collaborates with Planning and Marketing and clinical operational leadership on needs assessment for Women’s healthcare.

Leadership

1.  Integrates hospital’s primary departmental functions into clinical services. Develops and implements policies and procedures that guide and support provision of care.
2.  Recruits, hires, orients, and evaluates performance of assigned staff and other key positions. Has the authority to hire, terminate, and take disciplinary action for assigned staff in accordance with hospital policy and in collaboration with Employee Relations.
3.  Collaborates with operational leadership on the determination of qualifications and competency of department personnel who provide patient care.
4.  Supports orientation, in-service training, and continuing education throughout Women’s services.