Registered Nurse Manager - Medical Staff Quality & Projects HOT JOB

Manager of Medical Staff Quality & Projects

Pay Range: $46.87 - $65.76

The Manager of Medical Staff Quality & Projects is responsible for supporting the medical staff peer review, OPPE and FPPE processes throughout the consortium. This role encompasses reviewing medical records, identifying areas for improvement, and supporting initiatives aimed at enhancing patient care, safety, and overall hospital performance. The Manager of Medical Staff Quality & Projects will work closely with Quality Management and Accreditation team, medical staff, and department leaders to ensure that performance evaluation processes align with clinical standards, regulatory requirements, and hospital goals. The Manager of Medical Staff Quality & Projects will adhere to all regulatory and ethical standards including ensuring compliance with confidentiality as outlined by federal and state statutes, upholding ethical standards and working with Medical Staff Leadership, Quality and Credentialing to maintain the highest quality clinical practice standards.

SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.

Working at SEARHC is more than a job, it's a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health insurance, dental, and vision benefits, life insurance and long and short-term disability, and more.

Key Responsibilities:

Leadership and Oversight:

• Coordinates the Peer Review committee, sets agenda, facilitates or chairs meetings using Roberts Rules of Order, ensures productive and timely completion of reviews.
• Assist in the development, implementation and maintenance of comprehensive peer review, OPPE and FPPE policies and procedures aligned with regulatory requirements including federal and state statutes, accrediting agencies and hospital bylaws.
• Oversee the selection, training and ongoing performance evaluation of peer reviewers and ancillary staff

Clinical Review and Analysis:

• Coordinate and oversee the quality review of the medical staff peer review process to assess clinical performance, competency, and quality of care provided by healthcare professionals.
• Investigate and conduct review of medical records using clinical indicators approved by various subcommittees to assess appropriateness of treatment and compliance with current clinical practice guidelines.
• Use objective case findings and data to identify opportunities for improvement including patient safety issues and quality outcomes.
• Present specific cases, incidents, or performance metrics that need attention, highlighting key concerns, trends, or areas of improvement.

OPPE- Ongoing Professional Practice Evaluation:

• Assist, support and oversee the monitoring of OPPE processes and policies, which involve continuous evaluation of the clinical performance and professional competence of medical staff.
• Analyze performance data (i.e. patient outcomes, patient satisfaction, and clinical practice metrics) for ongoing professional practice evaluations (OPPE) to monitor the clinical competence and performance of medical staff on a continuous basis.
• Identify trends or areas of concern in clinical performance and collaborate with department leaders and medical staff to address these issues promptly.

FPPE- Focused Professional Practice Evaluation:

• Assist, support and oversee the monitoring of FPPE processes and policies for new providers, or providers seeking new privileges to assess their competence within the scope of requested privileges, or as a result of a peer review finding that requires a focused evaluation.
• Analyze performance data using clinical indicators approved by medical staff and various subcommittees as required to monitor the clinical competence and performance of medical staff.
• Review and monitor performance during the FPPE period, working with medical staff and leadership to determine appropriate corrective actions if needed.
• Analyze data and provide feedback on performance to ensure that FPPE activities are effective in addressing performance deficiencies and improving clinical outcomes.
• Ensure that FPPE processes are timely, well-documented, and compliant with hospital policies and accreditation standards.

Communication and Collaboration:

• Communicate findings and recommendations from peer review, OPPE, FPPE to medical staff leadership, providers and quality improvement departments. Communication must be professional, objective, concise and constructive with the goal of non-punitive actions and positive reinforcement.
• Attends all subcommittee meetings and QM meetings including OB, MEMC and WMC hospitalists, STA, Restraints, Trauma Quarterly Meetings, PQIC and CPIC and other quality/safety, patient care issue meetings as assigned or requested.

Reporting Structure and Compliance:

• All peer review activities and outcomes will be tracked using Smart Sheet or other format that will ensure accurate data extraction and will be in compliance with all regulatory standards.
• Quarterly Reports on peer review findings, trends, QM projects and systems improvements will be generated by the director and shared, as governed by relevant peer review statutes and regulations, with medical staff leadership and relevant stakeholders

Professional Development:

• The manager must stay updated on current healthcare trends, best practice in medical staff peer review, OPEE and FPPE and applicable regulatory standards and changes, and legal implications.
• The manager must pursue continuing education and keep updated on recent practice change guidelines and current best practice/standards of care relevant to the patient population being served by the hospital system.

Additional Details:

Knowledge, Skills and Abilities:

• Ability to work autonomously and maintain flexibility to prioritize safety issues, compliance issues and other rapidly changing needs in a growing healthcare system.
• Strong communication and team leadership skills, knowledge or experience in chairing meetings using Roberts Rules of order. Knowledge or experience in Accreditation Survey procedures.
• Experience or knowledge in leading RCA investigations from beginning to completion including implementation of systems changes and measurement of outcomes.
• Experience in CAH and hospital settings and the unique logistical challenges faced in Rural Health care, excellent problem-solving skills and use of resources.
• Skilled in Data Analysis and reporting

Education, Certifications, and Licenses Required:

• Current full, unrestricted Registered Nursing license in Alaska or other U.S. state required.
• Direct Hire must have applied for an Alaska nursing license before the start date.
• Agency staff must have an active Alaska license.
• BSN. Prefer a master's degree (or higher) or the ability to pursue within one year of hire.

Experience Required:

• 5 years of experience in healthcare.
• Experience in administration, quality improvement, case management, or other applicable experience is desirable.
• Demonstrated experience that shows leadership skills in facilitating and leading cross-functional teams and in working collaboratively with groups or teams.
• Previous experience facilitating multiple projects simultaneously while exhibiting strong planning and management skills.
• Strong clinical background relevant to the inpatient setting and hospital environment, including medical record review and data extraction.
• Working knowledge of medical practice guidelines, healthcare regulations and quality improvement methodologies.

Computer Skills:

• Proficient in Microsoft Office Products including Word, Excel, and PowerPoint
• Experience with various EHR system

Travel Required:

• Must be able to travel at least 10% of the time.

Safety and Risk Management Responsibilities:

• Employees are responsible for complying with safe work rules; reporting all accidents and injuries immediately; cooperating in all accident and injury investigations; reporting defective equipment and unsafe conditions.

Physical Demands:

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle or feel and reach with hands and arms.
• The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl. The employee must lift and/or move 50 lbs.

Work Environment:

• The noise level in the work environment is usually moderate.