The posting
Category:
Professional
City:
Jackson
State:
Tennessee
Shift:
8 - Day (United States of America)
Job Description Summary:
Responsible for supporting the medical staff department(s)/section(s)/committees that are accountable to oversee the quality of patient care, treatment and services provided by practitioner with privileges. Performs quality improvement (QI) activities, which include concurrent and retrospective chart review, observation of clinical and operational performance, and data collection and analysis. Coordinates the quality and peer review aspects of medical staff meetings, assists with external peer review as necessary, focused ongoing professional practice evaluation and ongoing professional practice evaluation. Serves as an educational resource on quality, patient safety and regulatory issues. Tracks and monitors compliance. Support performance improvement initiatives to promote a culture of safety in all clinical area and disciplines. Use and develop appropriate tools and strategies to analyze and present in the area of performance improvement. Uses appropriate quality tools and techniques to analyze and present data.
ESSENTIAL JOB FUNCTIONS:
- Uses clinical expertise to establish a system for identifying and reviewing practice/events that fall outside established standards of care utilized by medical staff governed quality and safety triggers.
- Communicates significant clinical findings with medical staff leaders to support best practices and standards of care improvement through the medical staff governance process.
- Participates in the medical staff department and committee meetings to exchange information and ensure consistency across all medical staff departments.
- Works within the established peer review process for case level review and/or enlists the appropriate parties to address any non-peer review issues that impact quality and patient safety.
- Assists in facilitating quality improvement efforts through the identification and validation of data elements for the medical staff and health system.
- Identifies and investigates medical staff complexities and issues as it pertains to patient care and involve appropriate stakeholders for policy changes and/or actionable items.
- Ensure the work of the department meets the accreditation and regulatory requirements for medical staff governance and oversight of the peer review process including but not limited to focus and ongoing professional practice evaluation (FPPE/OPPE).
- Serves as a resource to others in the resolution of complex problems and issues pertaining to provider peer review.
- Facilitates and coordinates all medical staff peer review committee and peer review subcommittee meetings.
- Prepares and distributes education from the peer review committee(s) to the appropriate medical staff department/committee/provider audiences.
- Attends numerous medical staff meetings as assigned.
- Gathers data from various sources for quality of patient care review, then enters into database.
- Maintains peer protected database for tracking all patient care reviews and medical staff findings. Utilize database to prepare review trends as needed or requested by medical staff leadership.
- Assembles, summarizes and presents clinical quality and safety information at medical staff meetings as required.
- Collaborates with appropriate leadership in regards to quality activities and any opportunities for improvement discussed in medical staff meetings as necessary.
- Prepares special reports. Designs, completes and presents studies as requested.
- Reviews individual charts as requested by the organizational leadership in regards to clinical quality and safety.
- Prepares information as necessary for external peer reviews, fair hearings and other activities as deemed necessary for the improvement of quality for the medical staff.
- Works with other quality personnel to incorporate service line and payer specific quality requirements and opportunities into the medical staff quality process as needed; actively engages in becoming subject matter experts in all quality programs relevant to the assigned medical staff departments.
- Participates in organizational clinical quality and safety improvement activities as requested.
- Assists in orienting new personnel in quality outcomes processes.
- Completes continuing education for improvement of job performance.
- Contributes to a positive work climate and overall team effort of the department and hospital, performs any related responsibility as required or directed and greets guests in accordance to our service excellence principles.
- Performs related responsibilities as required or directed.
JOB SPECIFICATIONS:
EDUCATION:
- Minimum of Associate Degree in Nursing or Allied Health Field required, BSN preferred.
- Minimum of 3 years’ experience in area of clinical expertise.
LICENSURE, REGISTRATION, CERTIFICATION:
- Current licensure as Registered Nurse or Allied Health Professional.
- AHA Basic Cardiac Life Support recommended.
EXPERIENCE:
- Knowledge of accepted clinical procedures as acquired through 3 years of clinical experience.
- Knowledge of the assessment of data, planning and coordination of care that will impact the fiscal management of patient care as acquired through on the job training.
- Knowledge of hospital policy and operations, medical and nursing staff procedures, hospital and community resources as acquired through on the job training.
KNOWLEDGE, SKILLS AND ABILITIES:
- Utilizes leadership / management skills.
- Knowledge and understanding of computer programs.
NONDISCRIMINATION NOTICE STATEMENT
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.
