Reports to Manager, Medical Staff Services. Manages the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) for all practitioners privileged through the Medical Staff Process. Leads Medical Staff Leadership in determining department quality indicators. Assures clinical appraisal and hospital activity components of medical staff credentialing process are complete for completion of initial FPPE and at reappointment. Serves as a subject matter expert regarding Peer Review laws, applicable accreditation standards, and Medical Staff Fair Hearing procedures. Serves the Medical Staff Services Department as a clinical resource. Work Duties also include various administrative responsibilities.
MISSION, VALUES and SERVICE GOALS
MISSION: We deliver outstanding care, inspire health, and connect with heart.
VALUES: Trust. Respect. Integrity. Compassion
SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Education and Experience
The knowledge, skills, and abilities as indicated below are normally acquired through the successful completion of a registered nursing program. Must have a current RN license in the State of Indiana. A minimum of 3 to 5 years of job-related experience is required. Experience in Medical Records, Medical staff affairs office, or quality review is preferred.
Knowledge & Skills
Must have current RN license in the state of Indiana.
Must be able to multitask.
Working relationship with hospital, State, Federal and voluntary guidelines for quality of patient care, confidentiality, and licensing.
Ability to interpret above information for Beacon Health System use.
Must be highly skilled in Microsoft Excel, Word, Powerpoint; Microsoft Access proficiency a plus.
Working knowledge of hospital and medical staff organizations.
Working knowledge of computer data systems.
Significant tact and discretion to effectively manage all responsibilities, excellent verbal and written communication skills and must maintain confidentiality.
Prolonged periods of sitting.
Prolonged periods of computer use.
Frequent periods of listening to and dealing with challenging situations.
Requires the physical ability and stamina to perform the essential functions of the position.
ESSENTIAL JOB DUTIES
The below statements are intended to describe the essential job functions and level of work performed by individuals assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by the personnel occupying this position.
Manages the Focused Professional Practice Evaluation (FPPE) Process:
Works closely with Medical Staff Coordinator’s to identify all providers who are requesting new privileges.
Review case lists of new providers to clinically determine which cases are appropriate for review by Medical Staff Leadership.
Holds Medical Staff Leadership accountable to complete reviews, in order to remove provider from FPPE.
Influences Peer Review Committee’s decision to initiate further monitoring if questions of competence arise.
Manages the Ongoing Professional Practice Evaluation (OPPE) Process:
Prepares and analyzes OPPE reports, performs initial clinical assessment of all OPPE for Medical Staff Leadership.
Influences Medical Staff Leadership by identifying outliers within their respective department and facilitates “next steps” to evaluate or drive improvement in individual provider performance, ie: Further retrospective case review, FPPE, Performance Improvement Plan, additional education, Prospective monitoring, etc.
Manages the Medical Staff Performance Improvement Program by:
Guiding the Medical Staff Leadership in establishing and revising department level quality indicators for monitoring and evaluating the quality of patient care.
Maintains a working knowledge of governmental, accreditation and industry wide quality indicators for departments and service lines.
Report outcomes of quality indicators for the Medical Staff, while maintaining the confidentiality of all material.
Guides the Medical Staff in interpretation of data, making recommendations and taking action.
Coordinating focus studies and researching medical literature when necessary to evaluate quality of care.
Performs initial clinical review of cases identified through department indicators; manages Medical Staff leadership review and follow-up.
Performs initial clinical review of all in-hospital mortalities and assigns outlier cases to appropriate department for peer review.
Maintains complete documentation of all activities.
Maintains all individual physician quality files.
Transmits quality assessment data between various departments and committees of the Medical Staff.
Reports peer review activity to the Peer Review Committee and the Medical Executive Committee.
Manages Medical Staff Peer Review Activities and Assist Chairman:
Assure hospital-wide communication by distributing agendas prior to, and minutes after, each Peer Review Committee and other committee meetings assigned, as required.
Lead committees in determining appropriate course of action upon review of cases and data.
Refer medical staff minutes, with appropriate action identified, to the Peer Review, and Medical Executive Committee meetings.
Prepare and communicate revisions to Medical Staff Bylaws, Rules and Regulations, Policies, Guidelines and plans as it relates to Medical Staff Quality Improvement.
Maintains a working knowledge of State and Federal Peer Review laws.
Lead Peer Review and Medical Executive Committees to formulate FPPE and Performance improvement plan that are compliant with applicable laws and accreditation standards.
Prepare Peer Review letters to providers as directed by Peer Review Committee, Medical Staff Officers, or VPMA.
Attend meetings as scheduled
Assures clinical appraisal and hospital activity components of medical staff credentialing process are complete at reappointment.
Report information on a timely basis to the Medical Staff Executive Committee, VPMA, Hospital President, all Medical Staff, and all appropriate Peer Review Committees.
Maintain files for all medical staff documents.
Maintain medical staff quality files separate from all other files per Indiana and Federal peer review laws.
Maintain familiarity with hospital, State, Federal and voluntary guidelines for quality of patient care.
Coordinate information and activity relating to quality of care.
Additional Salary Information: Salary will be based on direct experience in this type of role.
Internal Number: 195592
About Beacon Health System | Elkhart General Hospital
What makes a connection meaningful? At Beacon Health System, it’s our unwavering commitment to the health of the people we care for and the wellbeing of the community you call home. We are a locally owned, not-for-profit health system with medical teams and hospitals caring for our neighbors right here in Indiana and Michigan.
Headquartered in South Bend, Indiana, with 20 specialized partners and over 7,000 associates throughout the region, Beacon connects you with the care you and your family need to be your very best. That takes expertise: we are the regional leader in comprehensive, integrated services—everything from childbirth and pediatrics to mental health, cancer, trauma, heart, stroke, surgery, Telehealth and so much more.
And that takes empathy: leading with our hearts to make sure yours keeps beating—providing the best care, the best experience to each and every person. That is our calling. That is why we love what we do.