Address
Form of work Job Overview:
This position works collaboratively with the Medical Staff Department / Section Chairs, Service Line System Chiefs, and Nursing leadership in the development and support of quality initiatives to improve patient outcomes. Facilitates peer review of clinical performance within QA Committees and initiates further activity to support Medical Staff and improve care delivery. Identifies and evaluates patient care issues using applied knowledge, clinical experience, and analytical skills. Works in collaboration with physician / practitioner and nursing leadership to implement Professional Practice Evaluation to meet Joint Commission accreditation compliance requirements of providers. Supports root cause analysis, apparent cause analysis and other applicable Patient Safety activities.
Job Requirements:
Bachelor's Degree in Nursing or Bachelor's Degree in Health Administration, other related field
Registered Nurse
Current Ohio licensure
Cardiopulmonary Resuscitation (CPR)
Basic Life Support
Knowledge in field of specialty
Knowledge of quality assessment, quality improvement techniques, i.e., medical chart review
Excellent communication and customer service skills Experience in Data Analysis and Statistical Reporting
3-4 years experience Clinical in Nursing in specialty area of patient care relevant to the assignment and other extensive clinical, medical/surgical, or critical care experience
3-4 years experience Nursing in Quality Improvement and Medical Peer Review in a Healthcare setting
Job Responsibilities:
Collaborates with Medical Staff to perform physician peer review including FPPE and OPPE reviews in strict accordance with the established guidelines (TH and Joint Commission). Identifies trends and utilizes a proactive approach in notifying all Chairs for further follow-up and direction. Provides a summary incorporating assessment and analysis of FPPE findings and initiates appropriate corrective action. Reviews and evaluates patients' medical records and applies quality measures/criteria and utilizes hospital approved tools. Screens cases using clinical expertise and recommends referral for organized physician peer review. Provides necessary and appropriate follow through.
Formally prepares and presents quality narrative and statistical reports in a clear and objective format for the Medical and Administrative Staff (as required). Analyzes and validates quality outcome data and reports trends by practitioner, service line, or procedure. Proficiantly uses data systems, and skills with applications such as Excel, Word, and PowerPoint, and effective report development.
Acts as staff and/or participating member of various Specialty Quality Committees; responsibilities may include agenda planning/meeting organization, coordinating follow-up as directed, and assisting in the development of methods/tools and/or process for implementing projects/programs that have the potential to positively impact the quality of patient care.
Organizes and staffs all assigned Clinical Quality measures. Assists with the implementation of policies and procedures for the quality assurance and improvement function of TriHealth and assures compliance with The Joint Commission and other accrediting agencies and regulatory bodies. Facilitates commitment to an organization-wide quality structure and strategies for process improvement. This includes process development, data analysis and report preparation from the following databases: The Joint Commission/Centers for Medicaid and Medicare Services Core Measures, American College of Cardiology, Society of Thoracic Surgeons, Health Data Management, and Premier Clinical Advisor.
Works collaboratively with other healthcare providers and ancillary services as part of the Healthcare Team to provide the necessary effective measurement and analysis of the patient care services received. Effectively communicates and responds to requests in a timely manner to support efforts aimed at problem identification and effective resolution. Understands the roles and responsibilities of the key players, quality champions, and customers. Serves as a source of knowledge for area of expertise. Adapts traditional methodologies within a changing business environment. Collaborates professionally with staff and agencies.
Collaborates with Legal Counsel on matters associated with governing documents pertinent to the Medical Staff; assumes an active role for the dissemination of legal guidance and directives for system-wide alignment relative to peer review activities. Incorporates changes as needed to workflow designs, reducing system vulnerability through deliberate communication cascades and implementation of processes / practices throughout local department / section levels, including QA Committees.
Other Job-Related Information:
Indirect Report FTE's = 3-9
Working Conditions:
Climbing - Rarely
Concentrating - Consistently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Kneeling - Occasionally
Lifting <10 Lbs. - Frequently
Lifting 50+ Lbs. - Occasionally
Lifting <50 Lbs. - Occasionally
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Consistently
Sitting - Consistently
Standing - Occasionally
Stooping - Occasionally
Talking - Consistently
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Visual Acuity: Far - Consistently
Visual Acuity: Near - Consistently
Walking - Consistently
TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:
Serve: ALWAYS...
Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS...
Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
Offer patients and guests priority when waiting (lines, elevators)
Work on improving quality, safety, and service
Respect: ALWAYS...
Respect cultural and spiritual differences and honor individual preferences.
Respect everyone's opinion and contribution, regardless of title/role.
Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS...
Value the time of others by striving to be on time, prepared and actively participating.
Pick up trash, ensuring the physical environment is clean and safe.
Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS...
Acknowledge wins and frequently thank team members and others for contributions.
Show courtesy and compassion with customers, team members and the community
This position works collaboratively with the Medical Staff Department / Section Chairs, Service Line System Chiefs, and Nursing leadership in the development and support of quality initiatives to improve patient outcomes. Facilitates peer review of clinical performance within QA Committees and initiates further activity to support Medical Staff and improve care delivery. Identifies and evaluates patient care issues using applied knowledge, clinical experience, and analytical skills. Works in collaboration with physician / practitioner and nursing leadership to implement Professional Practice Evaluation to meet Joint Commission accreditation compliance requirements of providers. Supports root cause analysis, apparent cause analysis and other applicable Patient Safety activities.
Job Requirements:
Bachelor's Degree in Nursing or Bachelor's Degree in Health Administration, other related field
Registered Nurse
Current Ohio licensure
Cardiopulmonary Resuscitation (CPR)
Basic Life Support
Knowledge in field of specialty
Knowledge of quality assessment, quality improvement techniques, i.e., medical chart review
Excellent communication and customer service skills Experience in Data Analysis and Statistical Reporting
3-4 years experience Clinical in Nursing in specialty area of patient care relevant to the assignment and other extensive clinical, medical/surgical, or critical care experience
3-4 years experience Nursing in Quality Improvement and Medical Peer Review in a Healthcare setting
Job Responsibilities:
Collaborates with Medical Staff to perform physician peer review including FPPE and OPPE reviews in strict accordance with the established guidelines (TH and Joint Commission). Identifies trends and utilizes a proactive approach in notifying all Chairs for further follow-up and direction. Provides a summary incorporating assessment and analysis of FPPE findings and initiates appropriate corrective action. Reviews and evaluates patients' medical records and applies quality measures/criteria and utilizes hospital approved tools. Screens cases using clinical expertise and recommends referral for organized physician peer review. Provides necessary and appropriate follow through.
Formally prepares and presents quality narrative and statistical reports in a clear and objective format for the Medical and Administrative Staff (as required). Analyzes and validates quality outcome data and reports trends by practitioner, service line, or procedure. Proficiantly uses data systems, and skills with applications such as Excel, Word, and PowerPoint, and effective report development.
Acts as staff and/or participating member of various Specialty Quality Committees; responsibilities may include agenda planning/meeting organization, coordinating follow-up as directed, and assisting in the development of methods/tools and/or process for implementing projects/programs that have the potential to positively impact the quality of patient care.
Organizes and staffs all assigned Clinical Quality measures. Assists with the implementation of policies and procedures for the quality assurance and improvement function of TriHealth and assures compliance with The Joint Commission and other accrediting agencies and regulatory bodies. Facilitates commitment to an organization-wide quality structure and strategies for process improvement. This includes process development, data analysis and report preparation from the following databases: The Joint Commission/Centers for Medicaid and Medicare Services Core Measures, American College of Cardiology, Society of Thoracic Surgeons, Health Data Management, and Premier Clinical Advisor.
Works collaboratively with other healthcare providers and ancillary services as part of the Healthcare Team to provide the necessary effective measurement and analysis of the patient care services received. Effectively communicates and responds to requests in a timely manner to support efforts aimed at problem identification and effective resolution. Understands the roles and responsibilities of the key players, quality champions, and customers. Serves as a source of knowledge for area of expertise. Adapts traditional methodologies within a changing business environment. Collaborates professionally with staff and agencies.
Collaborates with Legal Counsel on matters associated with governing documents pertinent to the Medical Staff; assumes an active role for the dissemination of legal guidance and directives for system-wide alignment relative to peer review activities. Incorporates changes as needed to workflow designs, reducing system vulnerability through deliberate communication cascades and implementation of processes / practices throughout local department / section levels, including QA Committees.
Other Job-Related Information:
Indirect Report FTE's = 3-9
Working Conditions:
Climbing - Rarely
Concentrating - Consistently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Kneeling - Occasionally
Lifting <10 Lbs. - Frequently
Lifting 50+ Lbs. - Occasionally
Lifting <50 Lbs. - Occasionally
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Consistently
Sitting - Consistently
Standing - Occasionally
Stooping - Occasionally
Talking - Consistently
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Visual Acuity: Far - Consistently
Visual Acuity: Near - Consistently
Walking - Consistently
TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:
Serve: ALWAYS...
Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS...
Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
Offer patients and guests priority when waiting (lines, elevators)
Work on improving quality, safety, and service
Respect: ALWAYS...
Respect cultural and spiritual differences and honor individual preferences.
Respect everyone's opinion and contribution, regardless of title/role.
Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS...
Value the time of others by striving to be on time, prepared and actively participating.
Pick up trash, ensuring the physical environment is clean and safe.
Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS...
Acknowledge wins and frequently thank team members and others for contributions.
Show courtesy and compassion with customers, team members and the community
