Manager

Prior to each fiscal year (FY), the Chair working with the Departmental Administrator must construct a working budget and submit the new FY budget in accordance with appropriate WVUH and/or WVU SOM Finance guidelines within the established deadlines. The new FY budget should be based upon the performance of the current year's budget coupled with the projected financial changes that may occur within the next FY. The objective of the new FY budget is to forecast the best estimate of the actual charges, revenues and expenses of the Department.

At least twice during the fiscal year, the Chair and the Departmental Administrator should meet to review their Departmental budget with the Executive Leadership Group (Clinical Departments) or the Dean (Basic Science Departments). The Chair and Departmental Administrator should be prepared to interpret and explain any deviations in their budget. If a Department has a negative budget variance greater than 5%, they should self-report the reasons for the negative variance in writing to the ELG or Dean in a timely fashion. If requested, the Clinical Chair and the Departmental Administrator should also present an explanation of a budget with a negative variance to the UHA Board.

The Chair is responsible for the Departmental budget. Inherent to this responsibility, all Chairs are expected to have a fundamental understanding of basic accounting principles. They must be able to understand and interpret all aspects of their Departmental budget. They must be comfortable discussing their Departmental budget with their Departmental Administrator and with the WVU Healthcare CFO (Clinical Departments) or School of Medicine Financial Administration (Basic Science Departments). During the course of the fiscal year, the Chair and Departmental Administrator should review the budget on a monthly basis for any variances or inconsistencies. As a result of these monthly meetings, they must initiate any actions that may be required to maintain their anticipated profit margins.

The collection and dispersion of Departmental monies must conform to accepted ethical accounting principles. In particular, all Departmental funds must be used exclusively for Departmental activities and can never be used as a source of financial gain by any individual or any external organization. The Departmental Chair and the Departmental Administrator are directly responsible for monitoring that all Departmental funds are used appropriately.

The Department should report yearly on the status of Departmental Foundation and/or Research Accounts to WVU Development. Expenses to these accounts should conform with the intent of the funding source, and when appropriate, the Department should speak to why they have not utilized existing resources.

The Chair must insure that the Department has the appropriate number and types of faculty and staff to meet the Department's clinical and academic needs. The Chair working with the Departmental Administrator must constantly anticipate when faculty or staff may be leaving the program. With this in mind, they must initiate recruitment measures to insure that the Department operates in a smooth, uninterrupted fashion. Additionally, they must monitor any potential Department expansion that would require the recruitment of new faculty and staff.

The Chair and Departmental Administrator should be intimately familiar with the recruitment procedures established by Human Resources for staff and by the SOM Dean for faculty. West Virginia University is an equal opportunity employer and, to guarantee that status, the Chair and Departmental Administrator must have all recruitment applications reviewed by the Division of Social Justice.

Whenever an incident report or a written personal communication is submitted to the Chair about the actions of a disruptive faculty member or about a public display of conflict between personnel, action must be rapidly undertaken by the Chair to rectify the issue(s). The Chair should immediately collect information about the issue from as many sources as possible, so as to be able to best judge the breadth and depth of the problem. This includes meeting with the offending individual(s) to uncover their side of the story. For serious issues, the Clinical Chair should report the incident to Medical Staff Affairs (MSA) and seek the guidance of senior faculty members and Human Resources. Conversely, Medical Staff Affairs often learns of the events and works to notify the Chair. Together the Chair and MSA determine the course of action. MSA also tracks "complaints" such as disruption(s) and reports to the Chairs as part of the Ongoing Professional Practice Evaluation (OPPE) twice a year on all clinical faculty. The OPPE committee will frequently ask the faculty member to respond in writing to such complaints. For Basic Science Departments, the Chair should immediately inform the Dean's office of the issue and also seek the guidance of senior faculty members and Human Resources if required. If individuals have been clearly shown to be at fault for a current problem, the Chair must meet with the individual for an explanation of their actions. Following the meeting the Chair must send a written report of the meeting to the individual(s) and Human Resources. The report should include information about the content of the meeting's discussion and the action that will be taken by the Chair to insure that the incident will not reoccur. In the case of disruptive faculty, if the unacceptable behavior continues, the Chair must meet again with the individual(s) and issue a second verbal and written warning to the individual. The written warning should clearly state that if the behavior continues, the individual will be written up for a third time and referred to the Practitioner Health Committee in the Medical Staff Affairs Office..

The Chair should hold frequent (e.g., monthly) faculty meetings that are open to all faculty members. The meeting should contain any pertinent information about activities within the Department, School of Medicine and WVU that will directly affect the Department and its faculty. The Chair's office will keep accurate minutes of all meeting discussions. Prior to faculty meetings, the Chair will send a written meeting agenda and the minutes of the previous meeting to all faculty members. Any faculty member can submit items for consideration by the Chair for the meeting's agenda.

The Chair is responsible for the selection of committee members and committee Chairs. All committee vacancies should be filled by the Chair as soon as they occur. Customarily, Chairs review and reorganize Departmental committees in August in preparation for the academic year. Each Department should have, at a minimum, the following committees:

• Promotion and Tenure Committee
• Education Committee
• Faculty Search Committees

The Chair working with the Departmental Administrator must be directly or indirectly involved in the supervision of staff. In large Departments or in isolated Divisions it would be impractical for the Chair to be directly involved in the supervision of staff, however, the Chair must have periodic meeting with the staff supervisors to review staff performance. The Chair should be aware, at all times, of staffing issues.

Each Department should have a clearly defined listing of the Chair's Duties. This listing is to be used by the current Chair as a guideline for their daily, monthly and yearly activities. At least once a year, the Chair will review the job description for completeness and pertinence. At that time, the Chair should update the listing of Chair's duties and submit the revised listing to the SOM Dean.

The Chair is responsible for the efficient scheduling of the faculty's clinical, administrative and academic duties. The Chair, working with other administrative faculty members and staff, should publish clinical schedules for the use of their faculty members and clinical schedulers. The clinical schedule of each faculty member should reflect the faculty member's assignment of duties as defined in their yearly contracts. To meet the Department's scheduling needs, the Chair should also be aware of room usage and facility resources.

The Chair is ultimately responsible for reviewing credentialing of all faculty within their clinical department. Working with other Departmental administrative faculty, usually the Vice-Chair of Clinical Services, the Chair will establish a complete listing of requirements for all Departmental clinical privileges. The Chair (or designee) makes sure that credentialing is in line with specialty practices, society guidelines, and training requirements. The Chair (or designee) also works with MSA to ensure timely credentialing of new faculty members or when an existing faculty member wishes to add or change a privilege. The Chair is responsible for completing Focused Professional Practice Evaluations (FPPE) for all new faculty or new privileges at three, six, nine and twelve months and submitting the required forms to MSA. The listing of clinical privileges and/or any changes to the listing are submitted to and reviewed by the WVU Healthcare Medical Affairs Office. As new faculty join the Department or when current faculty wish to add a new clinical privilege, the Chair will review and confirm that all clinical requirements for the new Departmental clinical privilege are met by the faculty member.

The Chair will, at all times, be aware of the clinical and academic practices of Departmental faculty. These practices must reflect a code of ethics that is acceptable to both national medical societies and WVU Healthcare. It is the responsibility of the Chair to guarantee that all faculty are associated with acceptable, ethical medical practices. If the Chair becomes aware of any unacceptable medical practices, he/she must immediately meet with the offending faculty member for an explanation. The Chair must keep WVU Healthcare Legal Services, Medical Staff Affairs and the SOM Dean's Office aware of any potential unethical behavior and seeks their help in the handling of any unethical medical practices.

All patient care must be reviewed for appropriate outcomes. This review must be performed continuously by the Chair, Division Chiefs, and assigned senior faculty. Any adverse outcome from a clinical or surgical procedure must be presented in a monthly peer review conference (i.e. Morbidity and Mortality (M&M). The definition of adverse outcome is to be determined by the Department and must conform to the standards established by national medical societies and by WVU Healthcare.

All peer review conferences must be conducted by senior faculty chosen by the Chair. The senior faculty member assigned to M&M should review all cases prior to their presentation and they are responsible for keeping a written record of all presented M&M cases. He/she should strive to have in attendance all medical providers involved in M& M cases including, if possible, faculty from other clinical Departments that may have played a major role in the outcome of the M&M cases. The Chair must insure that all Departmental providers understand the M&M peer review process. The Chair must be personally familiar with all M&M cases and determine with the help of his/her senior faculty if any of these cases require additional investigations. Any M&M case that requires additional investigations should be reviewed by one or two senior faculty members, who are required to give the Chair a written report of their findings.

The Medical Staff Affairs office monitors quality through various avenues including OPPE/FPPE, M&M reviews, Quality of Care (sentinel event reviews), peer review committee (re-establishing this committee) and mortality committee referrals. In all cases the Chair (or designee) is asked to review the case and work with MSA to implement system improvements. From time to time the Medical Executive Committee has requested internal or external peer reviews. In the case of internal reviews, MSA has worked with the Chair to establish a small group of 2-4 faculty to review. In the case of external reviews, MSA has worked with the Chair to find appropriate reviewers.

The financial success of the Department is dependent upon correct, clear and timely documentation of each clinical encounter. The Chair, working with his/her billing Department, should continuously monitor the medical documentation of the clinical faculty to ensure that appropriate billing practices are followed. Whenever, the Chair or Departmental Billing becomes aware of incorrect documentation or an unacceptable billing decision, the Chair must take immediate action to rectify the problem. This may include meeting individually with the medical provider, sending clarification emails or having a billing/documentation presentation during a faculty meeting.

Dependent upon the size and nature of the Department's clinics, the Chair needs to meet on a regular basis with Departmental Directors/Chiefs and Clinic Managers. The frequency and the need for these meetings are at the discretion of the Chair; however, large clinics may require weekly or bi-weekly meetings while small clinics may require only monthly or bimonthly meetings.

The Chair should take advantage of the WVU Healthcare Planning, Marketing and Communication (PMC) Department for promoting the medical services of their Department. In order to best be able to market their Department, the Chair should be thoroughly aware of patient demographics, local competition, public opinion, and the major clinical selling points of their Department. The Chair should only market those services that the Department has the capacity to deliver.

Since the best Departmental marketing is constant marketing, the Chair should continuously be looking toward initiating new marketing strategies. Additionally, the Chair should be promoting Departmental activities that will indirectly market the Department. This would include participation in Health Fairs, appearances on the "Doctors on-Call" program, local lay presentations and formal press releases of any Departmental successes.

Recent marketing studies have shown that most consumers rely heavily upon the Internet for product information. This includes medical services. Therefore it is important that the Department develops a contemporary Departmental website that showcases the faculty, facilities and medical services of the Department. It is imperative that the website is up-to-date and eye catching. The website should be updated on a monthly to bi-monthly basis.

The hallmark of a great research department is the generation of ideas and new knowledge. No department is an island and the maintenance of a cutting-edge program requires the frequent interaction with scientists from other universities. These visiting scientists bring the knowledge of their own research but equally important is the opportunity for Department faculty to discuss their own research ideas and data with these individuals. Thus, it is the responsibility of the Chair to foster this program by providing fiscal resources and leadership to a program that regularly hosts external scientists to the department.

Each graduate student and research fellow needs the opportunity to hone the skills necessary to present a superb seminar on their research. Presentations of type will be required throughout their career and are the foundation to developing an effective teaching style if this is their career choice. The Chair should in concert with the Directors of the graduate programs foster a system that requires each student or research fellow to present at least one seminar annually and receive constructive feedback on the quality of the presentation from peers and faculty.

The skill required to critically evaluate published articles is acquired. The journal club forum allows students and faculty to present current literature articles for a dual purpose. First, it brings interesting and important articles to the attention of the students and faculty and it allows an in depth discussion on the data presented so that positive issues, new techniques, as well as less than optimal data can be brought to light. For the students and research fellows, this sets the foundation to perform this essential task throughout their career.

A department is judged by its research portfolio. The faculty look to the Chair to set the example on maintaining a funded research program. This leadership should include setting a positive example of the proper and ethical conduct of research, compassionate regard for research personnel and mentoring graduate students and post-doctoral fellows. The Chair must teach good fiscal and research practices (both in laboratory and clinical settings) by example, mentorship and actions.

A Chair should assist faculty in identifying start-up funds for faculty, residents and students. This process should also promote accountability where the outcome of start-up funded research is reported in forums such as a poster session or peer-review publication.

While some research programs remain relatively constant in size, others ebb and flow due to a number of factors. Key among these factors is funding, as this often requires new or different equipment (instruments) and changes personnel census. The Chair should monitor the needs for each faculty and when necessary (and possible) expand, contract or, in some cases, move faculty to provide optimal space for the faculty member's program in collaboration with HSC leadership.

Academic departments have or participate in a number of training programs, such as residency programs, medical student clerkships, and graduate student programs. It is essential that the effectiveness of these programs be optimal. The Chair should regularly meet with the Director of the programs that are part of their Department, or with which their faculty are involved, to enable the Chair to proactively or reactively change didactic and mentoring offerings as well as make fair informed decisions on the allocations of faculty time and effort.

Academic departments frequently provide service courses to Schools or Colleges at WVU. In many instances, these programs must meet external accreditation guidelines and standards. The Chair should meet with the appropriate directors of these programs to assure that courses and services provided meet or exceed the requirements of the program.

The Chair should be an active participant in the various committees that develop and enforce educational guidelines and goals of the department. These committees should be on a regular basis and at a minimum, annually review their decisions and seek input from the rank-and-file faculty not represented on the committee. It is essential that the Chair be more than a passive (ad hoc) participant because s/he is responsible for assuring that the Department complies with all university, state and federal regulations the relate to education.

The Chair must take an active role in these programs because s/he is responsible for assuring that the Department complies with all university, state and federal regulations as well as the accrediting bodies that have jurisdiction over these activities.

Management of faculty time is a key responsibility of the Chair. The Chair or her/his designee should keep an accurate inventory of the faculty's time commitments and, to the extent possible, balance the teaching loads across the faculty. It is recognized that this will be influenced by many variables, including discipline or topic coverage, as well as by differences in competing research and service contributions.

Teaching effectiveness of all faculty must be monitored by the Chair. Data collection should encompass a number of methods and could include a combination of direct observation, peer evaluation, and student evaluation (anonymous questionnaires). Meetings with the Directors of various educational programs served by the department should also include a discussion on the effectiveness of the teaching by the faculty serving that program.

At a meeting scheduled at the pleasure of the Dean, each Chair should review the Department's progress in all areas for which it is responsible.