This individual is responsible for conducting various activities and duties related to the Department of Surgery's Ongoing Professional Practice Evaluation, Focused Professional Practice Evaluation, and Initial - Appointment Focused Professional Practice Evaluation for Credentialing/ Re-credentialing. This individual performs monitoring activities, audits and investigations on a variety of issues for members of the medical staff and allied health professionals as outlined by the Professional Practice Evaluation Committee (PPEC) policy, including clinical quality of care measures and Core Measures issues. This individual also provides information to the PPEC and to the Medical Staff Department Chair, Surgery Section Head and OB/GYN Section Head in regards to creating and monitoring performance improvement plans for the medical staff. This individual participates in identifying clinical process improvement opportunities creating and effecting this process improvement. This person is responsible for facilitation and implementation of all aspects of the Surgical staff peer review process including medical record review of cases meeting established indicators, preparation of case summaries for physician review and follow-up as required. Communicates with consultants regarding requested or required external case reviews. Participates in weekly meeting with CMO to for purpose of review of any issues or concern related to medical staff or findings from PEER Review. Responsible for development and revisions of department specific procedures for activities related to the peer review process. Responsible for implementation of Focused Professional Practice Evaluation (FPPE) process for practitioners with new privileges and/or new procedure privileges and maintains database of results. Maintains databases of physician peer review credentialing/re-credentialing, and quality improvement activities through utilizing various software programs. Prepares a variety of reports utilizing statistical analysis as requested by the Department Director, VP/CMO, Medical Staff Department Chair and PPEC. Prepares monthly and quarterly summary reports of the Focused Professional Practice Evaluation process for the Credentials Committee, Medical Executive Committee and the Board. Responsible for compliance with related Joint Commission Standards, including monitoring of the Medical Staff for Improving Organization Performance. Works closely with the Director, VP/CMO, Medical Staff Services Coordinator, Clinical Abstractor, Clinical Data Coordinator, Quality Projects/Clinical Data Coordinator, and the Risk/ Patient Safety Coordinator.