The Peer Review Program Administrator is responsible for facilitation of the peer review and Professional Practice Evaluation (PPE) program, as well as related projects, of the organized medical staff to ensure ongoing practitioner competency, patient safety, engagement, and organizational compliance. Peer review activity and PPE is factored into the decision to maintain existing privileges, revise privileges, or revoke privileges prior to or at the time renewal. This role is responsible for department chair support with development, integration, and ongoing performance evaluation metrics, analytical and operational reporting (dashboards/scorecards), and ensuring departmental compliance with timely completion of reviews. This position develops detailed work plans, schedules, provides regular status reports and works with medical staff leadership to identify ongoing reporting needs to drive competency management systems. Provides expertise and education to hospital colleagues and medical staff on performance improvement strategies, methodology, tools, measurements, and documentation of outcomes. This position is an integral part of patient safety, quality assurance and performance improvement programming serving as a change agent to promote patient safety and practitioner engagement. Serves as a liaison between Medical Staff leadership and administration. Builds positive physician/practitioner relationships by actively engaging in dialogue, identifying areas of improvement, and working with leadership and other appropriate individuals to promote a culture of safety and engagement.

Essential Functions

Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.

Peer Review Coordination

Develops, facilitates, and monitors processes and procedures that support peer review, Professional Practice Evaluation, and other essential processes to ensure the ongoing competency and quality of the medical staff.
Manages, organizes, and coordinates the activities of the Medical Staff peer review program, including the direction and maintenance of a comprehensive and specialized peer review process.
Coordinates and facilitates multidisciplinary teams/committees. Monitors outcomes related to proven or potential events. Takes initiative to follow through on inquiries, problems, or requests.
Assists with corrective action recommendations, including FPPE, external case review and letters of reprimand.
Serves as a resource regarding medical staff peer review processes, procedures, and requirements. Follows, interprets, and assists with the development and enforcement of policies and procedures.
Participates in the development and implementation of ongoing process improvement initiatives to drive performance improvement and ensure patient safety.
Maintains confidentiality and ensures compliance with peer review policies and procedures.

PPE Management & Quality Improvement

Develop and implement processes for ongoing professional practice evaluation (OPPE), including development of metrics, building metrics, and coordinating metric integration. Monitors practitioner performance metrics and provide regular reports to leadership to identify opportunities for improvement.
Ensure accuracy and completeness of OPPE data and documentation.
Ensures compliance with focused professional practice evaluation (FPPE) requirements.
Develop and maintain escalation procedures for non-compliance.
Maintains and uses data and reports from systems to facilitate process improvement. Uses appropriate computer applications in data analysis and to facilitate data-based decisions.
Collaborate with medical staff quality management teams to identify areas for improvement and implement best practices related to peer review and PPE.

Information Management & System Administration

Track and analyzes trends and outcomes of peer review and PPE processes.
Works with physician leadership to develop metrics and strategies to improve performance.
Maintain accurate records of peer review and OPPE activities for tracking and appropriate follow through; Maintains an accurate peer review data base; collecting, entering and interpreting data; Ensures profiles and subgroups are kept up to date and accurate.
Maintains provider user accounts and control system access, scheduling reviews for new providers.
Midas/Statit administrator/superuser and assists with training, education, and performance improvement to promote optimum efficiency. Trains Chairs, Service Chiefs, and local users how to use the OPPE system.
Provide education and training to medical staff, medical staff leaders and committee members on peer review and OPPE requirements.
Prepare reports for regulatory agencies, accreditation bodies, and internal stakeholders.
Serves as part of the database support team.

Other

Participates in the development of Policies and Procedures.

Facilitates ongoing preparedness for accreditation and regulatory agencies.
Facilitates engagement-related activities and committees of the medical staff; ensures appropriate follow-up to promote medical staff engagement.
Serves as a champion and change agent for quality, safety and engagement by appropriately challenging current processes, policies, and procedures. Seeks to incorporate new technologies and methods to improve overall effectiveness. Seeks multidisciplinary expertise as necessary to solve problems and stay ahead of process developments.
Facilitates own personal professional development through participation in educational programs, in-services, and workshops and reading current literature.
Performs other related assignments as directed. Actively participates in committees and task forces as assigned.

Maintains a working knowledge of applicable Federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of conduct, as well as other policies & procedures in order to ensure adherence in a manner that reflects honest, ethical & professional behavior.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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