PI/Peer Review Coordinator - Performance Improvement - Full time 10 hours Days (Non-Union, Exempt)

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIES

Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others. Demonstrates exceptional customer service and interacts effectively with physicians, staff, leaders, and the broader health care community. Decision-Making/Judgment: Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus, when possible, communicates decisions to others. Escalates issues that do not conform to established expectations to the Director. Maintains confidentiality and always protects sensitive data. Computer Skills: Skilled in the use of computers, adapts to new technology, keeps abreast of changes, learns new programs quickly, uses computers to improve productivity. Initiative: Searches out and communicates best performance and quality improvement practices. Identifies and recommends corrective action plans for implementation when indicator measurement is below target. Tackles problems and takes independent action, seeks out new responsibilities, acts on opportunities, generates new ideas, practices self-development. At least 50% of CEUs are related to performance improvement, patient safety and/or peer review subject matter. Interpersonal Skills: Has effective active listening skills, builds strong relationships, is flexible/open-minded, negotiates effectively, solicits performance feedback, and handles constructive criticism. Works collaboratively and supports efforts of team members. Collaborates effectively, efficiently, and appropriately with Medical Staff Leadership and members. Job Knowledge: Understands duties and responsibilities, has job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. Serves as a resource for standards of care and practice related to patient care and safety and staff safety. Maintains expertise in data definitions for external reporting. Identifies cases meeting the criteria for clinical case review. Performs RN level of retrospective morbidity and mortality review using indicators and screening criteria. Conducts detailed medical records reviews for peer review, as appropriate. Maintains knowledge of evidence-based, CMS/CDPH and Joint Commission clinical metrics (i.e., core measures, AHRQ Patient Safety Indicators, Hospital Acquired Conditions). Personal Organization: Keeps information organized and accessible, maintains clean/functional workspace, works systematically and efficiently, manages time well. Problem Solving/Analysis: Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. Meets with physicians, nursing and ancillary staff and leaders to determine the root cause/barrier to compliance and formulate performance improvement strategies. Considers age-specific and cultural issues in problem-solving case specific issues. Applies statistical tools to determine root causes of identified problems including flowcharts, trending forms, bar graphs and control charts. Understands statistical variation: common cause versus special cause and uses it to focus corrective actions. Productivity: Manages workload, prioritizes tasks, develops good work procedures, manages time well, handles information flow. Ensures needed data is collected on a timely basis and reports on progress are regularly distributed. Manages workload, prioritizes tasks, develops effective, efficient procedures that minimize waste. Ensures the timely reporting of required issues/items to both external agencies, the Peer Review Committee, Quality Committees, PI related Committees, and the Director or Manager of Quality/Performance Improvement. Project Management: Establishes project goals, milestones, and procedures, defines roles and responsibilities, acquires project resources, coordinates projects throughout company, monitors project progress, manages multiple projects. Participates in or coordinates multi-disciplinary PI teams to support key quality and patient safety initiatives. Supports or coordinates the following projects as assigned: Core Measures and related inter-rater reliability, reporting and improvement; peer review; mortality review, and other priorities as established in the annual PI and Patient Safety plans. Ensures the relevant findings, conclusions and recommendations resulting from the Peer Review system is reported as required. Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, recognizes and acts on quality problems. Data results are validated prior to presentation and/or submission to external agencies. Reference sources are easily retrieved and available. The information provided is concise yet thorough. Corrections to work product are kept at a minimum and not repetitive in nature. Other duties, as assigned. JOB REQUIREMENTS Education Minimum (Required) Bachelor of Science in Nursing Preferred (Not required) Work Experience Minimum (Required) A minimum of five years of clinical experience is required with a preference for medical/surgical or critical care focus. Preferred (Not required) Two years of Quality/Performance Improvement experience preferred. Licenses and Certifications Minimum (Required) A current RN licensure in the State of California is required. Preferred (Not required) Certified Professional in Healthcare Quality (CPHQ) preferred Pay Transparency The hourly rate range for this position is $48.85 to $73.27 per hour. When extending an offer of employment, the University of Southern California Arcadia Hospital considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, State, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations

. POSITION SUMMARY Responsible for supporting and coordinating the assigned, organization-wide quality/performance improvement activities designed to improve patient outcomes and patient safety, in support of the hospital Performance Improvement Program. Supports the Medical Staff Peer Review Committee functions and the flow of information to Medical Staff groups and hospital departments. This role works closely with Medical Staff leadership on providing accurate clinical summaries, data trending, reports, and analyses. Performs chart reviews and abstracts data for quality and patient safety initiatives, such as core and quality measures, to determine compliance Federal and State regulatory requirements and Joint Commission standards. Collects, aggregates, analyzes, and reviews data for improvement opportunities. Collaborates with coworkers, staff, hospital leaders, and Medical Staff to achieve compliance and improvement with hospital initiatives. Assists and supports the Director or Manager of Quality/Performance Improvement, Administration, and the Medical Staff in fulfilling related responsibilities and reporting requirements. Provides evaluation, updating and assuring hospital adherence to established and newly implemented policies and procedures from recognized regulatory agencies. Works closely with the organized medical staff to fulfill their responsibilities of maintaining the quality of patient outcomes.

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Background Screening Policy Appendix D

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