PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
1. Manages Medical Staff Quality Monitoring
1.1 Serves as a resource for Medical Staff on quality improvement activities, education, and use of quality principles and tools.
1.2 Works collaboratively with the Medical Staff office to ensure compliance with Medical Staff regulatory and accreditation standards.
1.3 Collaborates with Medical Staff department and section leaders to select key specialty and department-specific performance indicators for inclusion on OPPE and FPPE reports.
1.4 Compiles Medical Staff OPPEs and FPPEs in accordance with hospital policy
1.5 Coordinates with Medical Staff Coordinator to summarize OPPE and FPPE data for presentation to Credentials Committee and Performance Improvement Committee, per policy
1.6 Distributes completed OPPEs to Medical Staff as a means of quality/performance improvement feedback
1.7 Ensures that an FPPE is initiated for every new provider appointed to the Medical Staff and every new privilege granted.
1.7 Serves as the primary liaison for Premier Physician Focus application.
1.8 Collaborates with the CMO and Medical Staff Department and section leaders to select key specialty and/or department-specific metrics to display on physician transparency feedback reports.
1.9 Oversees physician quality/transparency data metric extraction from Premier and distribution to providers on the medical staff.
2. Functions as the Peer Review Coordinator for Medical Staff Peer Review
2.1 Maintains current knowledge of quality indicators and review methodology as evidenced by accuracy of data.
2.2 Abstracts clinically pertinent information from patient medical records to prepare summaries for review.
2.3 Prepares all needed information for monthly meetings with Director to perform peer review.
2.4 Completes all required follow up activities and minutes in a timely manner according to pre-established deadlines.
2.5 Communicates with other departments concerning information needed to complete the peer review process.
2.6 Provides data for graphic representation of peer review indicators for PIC, MEC and Board reports as well as detailed information and assists with graphs as needed.
2.7 Notifies Director of all potentially litigious incidents identified through the Peer Review process.
2.8 Performs annual evaluation of peer review indicators and implements changes to indicators/process as indicated.
3. Oversees Participation with Evidence-Based National Hospital Quality Reporting
3.1 Serves as a resource for clinical and administrative staff related to Federal and State mandated quality measures.
3.2 Ensures accurate and timely reporting of abstracted and claim-based inpatient (IQR), outpatient (OQR), and psychiatric (IPFQR) quality data for submission to CMS and TJC.
3.3 Serves as liaison with corporate Quality & Safety team members regarding company directives for evidence-based measure selection and collection.
3.4 Supervises Quality Outcomes Analysts.
3.5 Supports Quality Outcomes Analysts in managing issues that arise with data collection or reporting, internally or externally.
3.6 Ensures information regarding Quality Payment Programs is analyzed for easy understanding and sharing with key organizational leaders, including Administration and the Board.
4. Supports the Quality Assessment/Performance Improvement (QAPI) Program and other Organizational Quality/Safety Initiatives
4.1 Actively participates in the annual revision of the Quality Assessment/Performance Improvement plan.
4.2 Participates on QAPI Committee and other committees and taskforces as assigned by the Director .
4.3 Ensures timely availability of assigned PSO Component data sets, for timely submission to the PSO.
4.4 Assists in training staff and physicians across the organization on QAPI concepts and improvement methodologies.
5. General Duties & Responsibilities
Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.
Is readily available for questions and handles requests in a courteous and respectful manner
Utilizes the Performance Improvement Model
Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicated.
Develops data reports for projects, committees, hospital departments, and medical staff departments as delegated
Utilizes statistical approaches, measurement techniques, and benchmark comparative data to develop quality reports
Participates in hospital-wide outcomes and quality improvement initiatives
Assists in efforts to improve and streamline the process and workflow of the department
Demonstrates the ability to set appropriate priorities.
Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.
When requested, is willing to adjust personal schedule in order to complete workload when necessary
Attends educational offerings as needed to promote continuous learning and support to department
The expertise and experiences you’ll need to succeed:
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
· Registered Nurse with unrestricted license in the state of North Carolina required.
EDUCATION AND EXPERIENCE REQUIRED:
· Bachelor of Science in Nursing
· Three years of experience in Quality data collection and analysis
· Knowledge of current federal and state quality measures
KNOWLEDGE AND SKILLS REQUIRED:
· Proficient in Word, Excel, and PowerPoint required.
· Possesses a high degree of concentration to interpret, and abstract and enter data accurately
· Proven analytical skills as demonstrated through data analysis
· Demonstrates skills and knowledge of process improvement tools
· Strong organizational skills;’ demonstrates the ability to manage time and meet deadlines
· Able to present information in a clear and concise manner.
· Demonstrates excellent management, communication, interpersonal, and team building skills.
· Able to communicate effectively in English, both verbally and in writing.