RN PEER REVIEW DATA ANALYST / REGULATORY AFFAIRS SPECIALIST

Overview:

The Peer Review Data Analyst/Regulatory Affairs Specialist is responsible for applying quality performance metrics and assessing provider performance identifying opportunities for improvement to increase provider knowledge, performance, and competence in relation to privileges granted to positively affect patient outcomes. Determines strategic objectives for the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes based upon clinical practice needs assessments, Peer Review results, and Quality Initiatives. Coordinates, directs, and analyzes FPPE and OPPE operations and data. Performs monthly Peer Review assessment of hospital wide medical staff complications and works with Peer Review Specialist MSQI to assess next steps of action. Serves as lead in data analysis and reporting of Medical Staff statistics and key performance indicators utilizing the MD Staff/Stat software system.

Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation.

Responsibilities:

FPPE/OPPE Management

• Coordinates the development of the OPPE universal and department specific measures and other focus reviews as assigned.
• Directs the Focused Professional Practice Evaluation (FPPE) which involves time-limited monitoring of a provider's practice performance:
• • when a provider is initially granted practice privileges;
  • when new privileges are requested for an already privileged provider;
  • when performance non-conformance involving a privileged provider are identified.
• Coordinates FPPE/OPPE reviews with the Medical Staff appointed physician leaders. Ensures timely completion and evaluation of all FPPE and OPPE evaluations per ACHC standards and Medical Staff Bylaws (minimum three performance assessments every two (2) years for every privileged provider on the Covenant Medical Staff).
• Assists in analyzing the FPPE/OPPE performance measure data and generates reports for physician leader's review.
• Composes correspondence letters to physicians and other providers as it pertains to FPPE/OPPE program results.
• Participates in quality assessment and improvement activities, identifies opportunities to improve services, makes recommendations, and implements actions as appropriate and consistent with the goals of the organization.
• Initiates the monitoring of professional performance as an ongoing process:
• • as part of the effort to monitor professional competency;
  • to identify areas for possible performance improvement by individual practitioners; and
  • to use objective data in decisions regarding continuance of practice privileges.
• Influences Medical Staff Leadership by identifying outliers within their respective department and facilitates "next steps" to evaluate or drive improvement in individual provider performance, ie: Further retrospective case review, FPPE, Performance Improvement Plan, additional education, Prospective monitoring, etc.
• Create, revise, or maintain policies and protocols addressing identified variations, including medical staff determination of validity, written explanation of findings, and, if appropriate, an action plan to include improvement strategies, the need for further training or proctoring, or amendment to privileges to help ensure positive patient outcomes.
• Enter and manage performance and peer review data within electronic credentialing and privileging systems.
• Develops and improves ASM/MD Stat software system for FPPE/OPPE Provider Report Cards with skill utilizing MD Staff for special reports as requested.

Proctor Compliance

• Monitors required compliance for provider proctor supervision and completion.
• Provides follow-up on completion of required proctoring assignments, assessment for criteria met for providers to ensure completion and then assignment to FPPE.

Data Analysis

• Assess Peer Review and Professional Practice Evaluation Program by identifying clinical competence thresholds, opportunities, and processes to achieve improvement, while working with medical staff leaders to develop strategies to enhance clinician performance.
• Utilizes feedback from Medical Staff leaders and team members, Department Chairs, Section Leaders, and other stakeholders to develop key performance indicators (KPI) and monitor appropriate progress towards those KPIs.
• Assures the confidentiality, protected status, and integrity of all aspects of Peer Review and Professional Practice Evaluation programs and provides special or routine reports to demonstrate individual or systemic successes or deviations through evaluation tools.

Complication Review

• Review monthly Complications report for possible critical actionable items.
• Utilizing Complication report, assess complications for all medical staff areas analyzing and comparing them to associated criteria to determine any next steps of review and action.
• Refer to MSQI those complications requiring medical staff leadership critical assessment and management by MSQI Committee with possible referral to Medical Executive Committee.
• Collaborates with Medical Staff leaders minimally every two (2) years to determine appropriate complication review criteria.

Cross Departmental

• Assist in administrative support and provide resources needed for the medical staff to enable them to fulfill their duties and obligations as defined by federal regulatory agencies, bylaws and rules and regulations.
• Participates in department and hospital programs for quality assessment and improvement, identifies opportunities for improvement, makes recommendations, and implements actions that are consistent with the goals of the organization as requested.
• Provides support to the Manager of Medical Staff Services, Chief Medical Officer and Chief of Staff by preparing and presenting ad hoc reports related to provider performance and evaluation.
• Ensures continuous compliance with regulatory bodies such as CMS, ACHC and others for applicable regulatory requirements, including consulting with regulatory bodies to demonstrate compliance.
• Communicate successes and deviations to practitioners and their department and medical staff leaders.
• Represent medical staff services on assigned committees as requested.
• In the absence of MSQI Peer Review Specialist, facilitate Peer Review Meetings (MSQI, SDMC, etc.) including preparation, attendance, feedback communication, transcription of minutes, and all other aspects of meetings.
• As required, possess the ability to create policies and procedures appropriate to duties being performed.
• Actively participates in meetings, as needed.
• Provides status updates on work to leadership.
• Performs other duties as assigned.

Qualifications:

EDUCATION/EXPERIENCE

• Bachelor's degree required.
• Must have and maintain a current Registered Nurse license in the State of Michigan.
• Three (3) years' experience in acute care hospital setting required.
• Experience with the utilization of an electronic medical record (EMR) for research and analyzing patient records to complete monthly complication evaluation, review and direction in relation to evaluation criteria; EPIC EMR; and patient safety & quality preferred.

KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge of accreditation standards and State and Federal requirements.
• Familiarity with hospital accreditation requirements in addition to Federal and State compliance standards.
• Strong medical terminology and pharmacology knowledge
• Strong skills in use of ASM / MD Stat database software for collection, distribution and reporting out of FPPE/OPPE provider performance.
• Strong skills in Microsoft Excel, Word, PowerPoint and Adobe.
• Excellent communication skills to effectively convey project goals, objectives and expectations to team members, stakeholders, team members, and senior management.
• Ability to manage time effectively and ensure that projects are completed on time or project timelines adjusted to compensate for challenging projects or other circumstances.
• Demonstration of leadership skills with ability to interact and direct all levels of individuals.
• Ability to work and communicate effectively with various levels of management personnel, physicians, universities, nurses, other IRBs, regulatory inspectors, etc.
• Advanced skills and experience in leading and facilitating groups, decision-making and conflict resolution.
• Ability to independently make sound decisions and direct workflow.
• Excellent time management and organizational skills with attention to detail.
• Excellent analytical, critical thinking and problem-solving skills.
• Demonstrates ability to maintain information in a confidential manner.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Ability to maintain punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.
• Frequent standing, walking, sitting, handling, feeling, talking, hearing and near vision.
• Occasional lifting 0-10 lbs.
• Occasional reclining, lifting, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, squatting, crawling, twisting, reaching, far vision and depth perception.