Department: Quality Resources
Category: Professional
Schedule: Full Time
Shift: Days
Hours: 8:00-4:30 pm

Basic Function:

Coordinates an effective medical staff peer review process that supports medical staff reappointment, advancement, and clinical quality in compliance with Joint Commission ongoing physician performance evaluation (OPPE), focused professional practice evaluation (FPPE) standards.  Performs review of medical records, including record abstraction, for core measures and other clinical indicators based on established definitions for peer review for assigned populations and provides timely feedback to clinical management and physicians to ensure optimal quality patient care. 

Specifications:

1. Registered Nurse with a Bachelor?s degree in nursing or other health-related field required. 


2. Four years experience in an acute general hospital required, with two years progressively independent roles preferred. 


3. Independent in use of WORD, EXCEL and internet-based peer review and data entry programs.


4. Possess excellent oral, written and interpersonal communication skills.


5. Possess excellent organizational and analytical skills


6. Possess ability to plan, organize and integrate complex and inter-departmental programs.


7. Light physical effort.

Scope of Supervision:

Supervises      0         employees

Principle Responsibilities

(Indicate Responsibilities essential to the position by indicating an ?E? to the left of the number):

E.    1.     Responsible for coordinating effective physician peer review, assessing the quality of medical care by performing a professional, objective review of each case that meets identified indicator criteria to determine the need for inclusion in the peer review process utilizing clinical judgment, critical thinking skills, and knowledge of clinical care guidelines and national priorities for care. 

E.    2.     Performs professional, objective medical record review of each case identified regarding

appropriateness of patient care based on evidence-based outcomes and clinical guidelines, working with the department chairman, Chief Medical Officer and Physician Peer Review Committee to identify process deficits, trends and/or practice patterns. 

      E.   3.    Assists Department and Committee Chairperson or designated physician peer reviewer in

case review performance and documentation, including providing education regarding the peer review process, assistance in navigating the electronic medical record and/or peer review database.

E.    4.   Responsible for facilitating current physician performance evaluation activities in accordance with Joint Commission requirements including preparation of case summaries and accurate, timely electronic documentation in an online peer review database for every case review for each medical staff department and committee involved in monitoring/improving quality and appropriateness of care. 

E.    5.   Promotes system improvement through data collection and analysis as defined by Joint Commission/CMS hospital core measures, performance measure initiatives and the medical staff, including: performing extensive medical record reviews and abstraction of data on all regulatory clinical indicators ensuring reliability, validity and timely electronic submission of core measure data.  Assists in interpreting and/or analyzing the results to provide physicians with systematic, timely and periodic feedback on performance.

E.    6.   Utilizes superior discretion and ability to maintain confidential, sensitive physician peer review information.  Use appropriate safeguards to prevent inappropriate use or disclosure of confidential case review information.

E.    7.   Compiles data for studies involving medical care evaluation/improvement efforts, including obtaining statistical analysis by utilizing support personnel within the health system.    

E.    8.   Maintains Core Measurement knowledge through self-development and keeps current on all changes related to Core Measurement requirements, serving as a resource to staff, management and physicians. 

E.    9.    Reports all opportunities identified to improve processes, policy/procedures.

E.    10.   Coordinates and/or attends department and committee meetings.  Prepares, or assess with preparation of, agenda and materials presentation.  Records minutes at specified committee meetings.

E.    11.   Works collaboratively with a wide range of healthcare professionals including providers, other healthcare leaders and medical records personnel.

E.    12.   Develops the Medical Staff Peer Review Process Flow Sheet, updating when indicated.

E.    12.   Continually assesses and improves upon the tools and mechanisms for which information is gathered for Physician Peer Review activities, including indicator selection and application. 

E.    13.    Performs additional duties and responsibilities as requested. 

Date posted: 09/24/2010