Facility: Kennestone Hospital

Job Summary:

The Coordinator is responsible for facilitating the medical staff Peer Review, Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) functions in accordance with The Joint Commission (TJC) Standards, CMS Conditions of Participation, WellStar Medical Staff Bylaws and Professional Practice Evaluation Policy. Analysis of events that require peer review and the examination of medical records as identified by clinical indicators or triggers is an integral part of this role. The Coordinator is responsible for managing and maintaining the confidentiality of the peer review process, quality records and performance improvement documentation to support the Professional Practice Evaluation Policy and Medical Staff Credentialing process. Prepares and maintains physician quality documentation, quality profiles as well as other assigned physician related performance improvement projects related to FPPE/OPPE. Supports the hospital Peer Review Committees and the hospital Vice President of Medical Affairs (VPMA).

Core Responsibilities and Essential Functions:

Peer Review Operations * Manages and facilitates timely completion of peer review activities of the organized medical staff. * Identifies and screening referrals as defined by the Medical Staff using both qualitative and quantitative data sources. * Must understand basic quantitative data and be able to perform case reviews. * Prepares cases for review by a peer reviewer of peer review committee * Must be able to summarize complex clinical cases into a summary that illustrates the issues being reviewed. * Communicates as per policy to the provider being reviewed, organizes communication from the provider to the peer review process for presentation to peer reviewers and peer review committees * Must be reliable and high attention to detail to ensure timely communication. * Collaborates with other system data analysts to provide additional data/drilldown when needed. * Has a basic understanding of relationship and reliability methods, and just culture concepts. * Should understand basic root cause analysis process and concepts. * Assists with metric creation that is supported by clinical evidence. * Conducts chart review to understand the data; utilizes pre-determined criteria in chart review to ensure consistency of the review. * Communicates and collaborates with other hospital PICs, service line quality committees, and department chairs. * Collaborates with other disciplines to understand opportunities; works to align physicians, team members, and administration in an effort to focus on common clinical processes of care. Facility Operations * Maintains a working knowledge of governmental, accreditation and industry wide quality indicators and regulatory requirements for departments and service lines, State and Federal Peer Review Laws, Medical Staff Governance documents and policies, Medical Staff database, and Practitioner data analytics applications. * Supports the Medical Staff by reporting outcomes of quality indicators and guiding the interpretation of the data to lead to a recommendation of action. Applies information learned from focus studies and medical literature. * Actively screens cases in preparation for or in lieu of review by a peer review physician, when applicable. * Coordinates department-specific peer review process in a timely and effective manner, from the identification of cases to be reviewed through the necessary actions and follow-up with specific providers. * Ensures entry of all FPPE, OPPE and Peer Review data within the Practitioner Credentialing Data Repository (ECHO) is completed timely and is accurate. * Reports information on a timely basis to the applicable medical staff, committees, Department Chair, VPMA, Hospital President and appropriate Peer Review Committees * Completes other job-related duties and projects as assigned. Supports Focus Professional Practice Evaluation (FPPE), Privileging, and Credentialing Process * Works closely with Medical Staff Coordinators to identify all providers who are requesting new privileges or additional privileges * Conducts retrospective reviews on designated independent cases and compiles a summary to the department chair upon completion. * Collaborates with the committee chair and members to define and develop performance monitoring for a practitioner with issues affecting provision of safe high-quality patient care. * Populates and maintains practitioners electronic quality files to ensure performance reports and dashboards are accurate. * Adheres to all procedures within the Professional Practice Evaluation Policy and/or Medical Staff Policies that guide the FPPE activities. Focus Professional Practice Evaluation Performance Improvement Plan (PIP) * Coordinates performance improvement actives according to the professional practice evaluation policy to include chart review, implementation of PIP activities and reporting, and maintains all documentation related to the PIP. * Maintains PIP status and completion reports that are periodically reported to applicable committees Ongoing Professional Practice Evaluation (OPPE) and Re-Credentialing Process * Monitors department triggers/indicators and identifies trends and outliers. * Aggregates, analyzes and communicates the OPPE summary to the department chair upon completion. * Supports the Medical Staff by evaluating or driving improvement in individual provider performance through further retrospective case review, FPPE, Performance Improvement Plan, additional education, prospective monitoring, and other. * Populates and maintains performance files and/or dashboards for medical staff departments Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelor's Degree Required and Nursing or healthcare-related field Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Cert Prof Healthcare Quality-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 4 years experience in healthcare, nursing or clinical practice Required and Minimum 2 years of experience in peer review, risk prevention, or quality Preferred

Required Minimum Skills:

Proven ability to analyze, interpret, and display data; strong attention to detail; meticulous accuracy and thoroughness. In depth knowledge of medical terminology. Strong organizational, analytical and problem-solving skills with the ability to work independently as well as with a team. Demonstrated excellence in interpersonal and written communication skills required. Must demonstrate the ability to accurately use a computer and standard office software such as Microsoft excel, word, access and power point. Knowledge and competency with data reporting systems. Aptitude in collaborating with teams that include key stakeholders and/or leadership to reach consensus. Ability to coordinate multiple tasks and flexibility to balance changing priorities. Ability to build relationships and foster communication among stakeholders in clinical and non-clinical settings.