Uses advanced skills in quality assessment to perform comprehensive quality of care and patient safety to develop validated care standards, data repositories, physician peer review indicators and outcome measurements related to the care of patients. Collects and analyzes benchmarking data, focus studies, and clinical indicators. Provides education, ensures loop closure, prepares reports, presents outcomes and participates in organizational-wide continuous improvement projects as it relates to Performance Improvement, Peer Review and Patient Safety program.

1. Accurately and completely abstracts data from the patient's medical record, including, but not limited to, sepsis and cardiac-related registries.
2. Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans.
3. Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Steering Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures.
4. Facilitates identification and documentation of hospital-based approved performance improvement variances and complications.
5. Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities.
6. Assists with the development and coordination of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program.
7. Lead multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
8. Assess the need for and facilitates the development of ongoing physician practice evaluation triggers.
9. Generates annual report information regarding activities and prepares statistical data.
10. Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations.
11. Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
12. Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
13. Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement.
14. Oversees physician peer review data is entered in the appropriate database in a timely and accurate manner.
15. Assists with preparation of monthly Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) reports.
16. 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.
17. Assists with preparation of quarterly peer review reports that are reported up to appropriate ULH committees.
18. Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
19. Attend safety huddle to report any safety trends found in chart review.
20. Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation.
21. Performs other duties as assigned

Education / Accreditation / Licensure (required & preferred):
• Bachelor of Science Degree in Nursing required, Master of Science in Nursing or other healthcare related master’s degree preferred. Certification in specialty preferred.

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

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