RN Peer Review & Performance Improvement Coordinator

Job Title

Job Title

Job Description

UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute and Brown Cancer Center. With more than 12,000 team members - physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals - UofL Health is focused on one mission: delivering patient-centered care to each and every patient each and every day.

Responsibilities

Abstracts and enters data into data management systems as requested to support Performance Improvement, Peer Review, and Patient Safety Program
Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans
Facilitates identification and documentation of hospital-based approved performance improvement variances and complications
Analyzes benchmarking entity mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities
Assists with safety event management, analysis and investigations


Other Functions:
Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Committees and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures
Assists with the development and coordination of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program
Lead multi-disciplinary projects related to the hospital's overall goal to become a 5-star Vizient organization
Assess the need for and facilitates the development of ongoing physician practice evaluation triggers
Generates quarterly & annual report information regarding Quality and Safety activities, and prepares reports and statistical data
Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations
Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) reports
Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications
Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement
Oversees registries &/or physician peer review, ensures data is entered in the appropriate database in a timely and accurate manner
Attends Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee when appropriate.
Assists with preparation of quarterly peer review reports that are reported up to appropriate ULH committees.
Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
Attend safety huddle to report any safety trends found in chart review
Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation
Demonstrate the ability to present quality, performance improvement and safety data after analyzing and identifying any trends and/or patterns
Maintains compliance with all company policies, procedures and standards of conduct
Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
Performs other duties as assigned

Job Requirements

Education:
Bachelor of Science in Nursing (BSN) (required)
Master of Science in Nursing (MSN) or other healthcare-related master's degree (preferred)


Experience:
Five (5) years of acute care, hospital-based clinical experience in area of intended practice (required)
Previous experience in academic teaching hospital (preferred)


Licensure:
Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky


Certification:
Certification in specialty (preferred)