PI Quality Analysis Full Time Days

Description

Desert Regional Medical Center is a 385-bed acute-care hospital classified as a stroke receiving center and level 2 trauma facility with an innovative, patient centered and evidence-based Rehabilitation Services Department. Our compassionate team provides a wide range of inpatient and outpatient services, including acute care rehabilitation, joint replacement & spinal surgery, neurosurgery, ICU, Telemetry, step-down care, skilled nursing, as well as outpatient therapy, hand and lymphedema clinics.

General Duties:

The Peer Review Coordinator will support the hospital’s medical staff peer review function in compliance with Joint Commission Standards, Title 22 for California, CMS Conditions of Participation and the Medical Staff Bylaws. The Peer Review Coordinator will manage the peer review process from acceptance of cases for peer review, facilitating first level screening if applicable, preparation of case review documents, and documentation of peer review results, production of reports and maintenance of the peer review data base. This position will also support the DCQI and the organization through use of clinical expertise in review of concerns regarding quality of clinical care.

Shift: Days

Hours:

2503001584

• Works directly with the Chair of the Medical Staff Peer Review Committee to assure the peer review process is functional and works to improve the quality of care provided by the medical staff.
• Works in conjunction with the Director of Medical Staff Services to meet the medical staff Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) policies.
• Works with the Quality Decision Support Analyst to produce OPPE reports for all medical staff members every 6-8 months.
• Collaborates with the Manager of Accreditation and Licensing to include evidence-based medicine outcomes through core measures in the peer review process. 
• Is responsible to manage and appropriately document the peer review process from initial case review, review findings and outcomes 
• Conducts or refers cases for first level screening and/or clinical review, working with the DCQI, Patient Safety Officer, and Quality Analysts.
• Arranges and attends the Medical Staff Peer Review Committee meetings, facilitating the peer review process, documenting the peer review results, and referring cases as directed. Prepares committee minutes. 
• Prepares the Medical Executive Committee Peer Review Report monthly. 
• Facilitates peer review in the Quality Department through interaction with medical staff members, providing guidance and direction as needed.  Develops and maintains professional relationships with medical staff leaders, members and hospital staff. 
• Incorporates peer review from medical staff committees and departments into the peer review database to provide an accurate representation of the practice of medical staff members. 
• Maintains knowledge of all standards and regulations involving medical staff peer review and assures compliance.  Understands and complies with the peer review process as outlined in Medical Staff Bylaws.
• Incorporates information from eSRM reports, adverse events, and other sources into the peer review process. 
• Facilitates quality of care reviews with subject matter experts if necessary to facilitate peer review.
• Ensures confidentiality with patient and physician information, PHI, and demonstrates understanding of HIPAA.  Also understands and upholds protections of California Evidence Code 1157 and the federal Healthcare Quality Act. 
• Answers the phones and responds to customer needs professionally and without complaints.
• Participates willingly in department meetings to enhance team work and efficiency with in the department.
• Willingly takes on additional assignments as needed within the department, including providing back up for other Quality Services staff as necessary. 
• Reports to work on as scheduled on time, sufficiently rested to perform duties of the job.
• Takes initiative in keeping Director fully informed on work related issues.

 

Qualifications

Required:

• At least 2 years experience in acute hospital risk management, patient safety or quality improvement; or equivalent experience as a registered nurse with active California licensure.
• Excellent interpersonal, communication skills.
• Proficiency in Microsoft Office 

Preferred: 

• Current CA RN license with a minimum of 5 years experience in acute hospital setting
• Bachelor’s degree preferably in a health-related field.
• Experience in a medical staff peer review process.
• Experience with Access or similar data bases.

 

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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.