RN Peer Review & Performance Improvement Coordinator

•    Abstracts and enters data into data management systems as requested to support Performance Improvement, Peer Review, and Patient Safety Program
•    Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans
•    Facilitates identification and documentation of hospital-based approved performance improvement variances and complications
•    Analyzes benchmarking entity mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities
•    Assists with safety event management, analysis and investigations
Other Functions:
•    Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Committees and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures
•    Assists with the development and coordination of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program
•    Lead multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
•    Assess the need for and facilitates the development of ongoing physician practice evaluation triggers
•    Generates quarterly &annual report information regarding Quality and Safety activities, and prepares reports and statistical data
•    Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations
•    Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) reports
•    Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
•    Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications
•    Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement
•    Oversees registries &/or physician peer review, ensures data is entered in the appropriate database in a timely and accurate manner
•    Attends Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee when appropriate.
•    Assists with preparation of quarterly peer review reports that are reported up to appropriate ULH committees.
•    Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
•    Attend safety huddle to report any safety trends found in chart review
•    Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation
•    Demonstrate the ability to present quality, performance improvement and safety data after analyzing and identifying any trends and/or patterns
•    Maintains compliance with all company policies, procedures and standards of conduct
•    Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
•    Performs other duties as assigned