Medical Review Organization, Quality Improvement Organization
DEPARTMENTAL SUMMARY: The Medical Staff Services (MSS) Department of St. Charles Health System, is the gatekeepers of patient safety within the healthcare industry. The professionals working in Medical Staff Services serve as the experts in matters of credentialing and medical staff governance within the healthcare community. This foundation is the basis upon which safe and quality care can be assured for patients.
POSITION OVERVIEW: The St. Charles Health System’s Peer Review Program Nurse Supervisor manages the Focused Professional Practice Evaluation (FPPE) and support of Medical Staff Morbidity and Mortality case review for all practitioners privileged through the Medical Staff Process. Supports Medical Staff Leadership in determining department quality indicators. 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.
This position does not directly manage any other caregivers, but does provide education, support, and training of other MSS staff.
ESSENTIAL FUNCTIONS AND 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.
Coordinates Manages the Focused Professional Practice Evaluation (FPPE) Process
Works closely with Medical Staff Leadership, the CMO and Medical Staff administrative team to identify all providers who may be subject to FPPE.
Reviews 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 assess appropriateness of removing from or sustaining providers in ongoing FPPE
Working with the CMO, informs and supports Peer Review Committees' decisions to initiate further monitoring if questions of competence arise.
Manages Morbidity and Mortality Review (MMR) Process
Prepares and analyzes case reports, performs initial clinical assessment of all potential cases for MMR for Medical Staff Leadership
Influences Medical Staff Leadership by identifying events indicating need for MMR within their respective departments and facilitates "next steps" to support improvement in individual provider performance, e.g., further retrospective case review, FPPE, Performance Improvement Plan, additional education, Prospective monitoring, etc.
Manages the Medical Staff Performance Improvement Program by:
Works with and supports the CMO, Medical Directors and medical staff leaders in development and application of criteria for MMR and FPPE processes
Supports the Medical Staff Leadership in establishing and revising department level quality indicators for monitoring and evaluating the quality of patient care re criteria for MMR.
Maintains a working knowledge of governmental, accreditation and industry wide quality indicators for departments and service lines
Report outcomes of FPPE indicators for the medical staff, while maintaining the confidentiality of all material
Supports the Medical Staff in interpretation of data, making recommendations and taking action as directed by the CMO or medical staff leadership, coordinating focus studies and researching medical literature when necessary to evaluate quality of care
Performs initial clinical review of cases identified through department indicators and as directed by the CMO, Medical Directors and/or medical staff leaders; supports medical staff leadership review and follow-up
Performs initial clinical review of all in-hospital mortalities with the CMO and medical directors, assigning cases to appropriate department for review as directed;
Supports the Mortality Review Committee
Works with the Quality and Safety department leadership to appropriately use quality indicator information to direct FPPE and MMR work.
Maintains complete documentation of all activities
Maintains FPPE information in a confidential matter for all individual physician files
Transmits FPPE and MMR data confidentially between various medical staff leaders and committees as directed by the CMO or Presidents 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
Under the direction of the Peer Review Committee Chair - assure appropriate communication by distributing agendas prior to, and minutes after each meeting of the Peer Review and Mortality Review Committees and other committee meetings assigned, as required
Support committees in determining appropriate course of action upon review of cases and data
Transfer information with appropriate action identified, to the various medical staff department chairs, section chairs, Peer Review Chair, and Medical Executive Committee meetings
Maintains a working knowledge of State and Federal Peer Review laws
Support Peer Review and Medical Executive Committees in formulating FPPE and Performance improvement plans that are compliant with applicable laws and accreditation standards
Prepare Peer Review communication (letters) to providers as directed by Peer Review Committee, Medical Staff Officers, or CMO
Attend meetings as scheduled
Assures clinical appraisal and hospital activity components of medical staff credentialing process are complete at reappointment
Reports information on a timely basis to the Medical Staff Executive Committees, CMOs, Hospital Presidents, all Medical Staff committee chairs, and all appropriate Peer Review Committees
Maintain files for all medical staff documents pertaining to FPPE and MMR
Maintain medical staff quality files separate from all other files per Oregon 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 with CMOs, Medical Directors, medical staff leadership and the St. Charles Health System Quality and Safety department.
Contribute to the overall effectiveness of the department
Completes other job-related duties and projects as assigned by the Bend and Redmond CMO or Director of Medical Staff Administration
Supports the vision, mission and values of the organization in all respects.
Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
May perform additional duties of similar complexity within the organization, as required or assigned.
Required: Bachelors degree in Nursing (BSN)
Preferred: Masters degree in Nursing (MSN)
Required: Oregon RN License; Valid Oregon driver's license; Ability to meet St.Charles Health System driving requirements.
Preferred: Certified Professional Medical S(CPMSM) and/or Certified Provider Credentialing Specialist (CPCS); On going maintenance of certification.
Required: Minimum of 5 years experience in hospital setting working with physician providers.
Preferred: Experience in Medical Records, Medical staff affairs office, peer or quality review are preferred.
Additional Salary Information: Salary is assessed based on existing internal equity, and employee experience.
Internal Number: R1006217
About St. Charles Health System
St. Charles Health System is a private, nonprofit organization, dedicated to providing high-quality care and the latest in health care technology to the communities it serves. Headquartered in Bend, Ore., St. Charles is an integrated delivery system, with a strong focus on population health, that provides a full range of evidence-based health care services within a 32,000-square-mile area in Central and Eastern Oregon.
The health system owns and operates a trauma level II, tertiary referral center in Bend, a trauma level III, type B rural hospital in Redmond, and trauma level IV critical access hospitals in both Prineville and Madras. As the largest employer in Central Oregon, St. Charles Health System and St. Charles Medical Group care for our communities in more than two dozen outpatient clinics and in more than 20 specialty areas of medicine.