DescriptionJob SummaryResponsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department manager's, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight