To provide leadership, direction and assistance to the hospital and the medical staff to achieve the goals of the Performance Improvement (PI) Plan. Serves as a resource, an educator and a consultant. Ensures accurate data collection, analysis, and reporting to establish and maintain practice standards and organization-wide PI efforts. Responsibilities: Responsibilities related to medical staff PI Screens cases to identify issues for physician review, using criteria established by the medical staff and the NYS DOH. Initiates the peer review process by reviewing cases identified through the screening (mortalities, OR incidents, infections, etc.). Documents findings in MIDAS within established time frames.