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Posted: 31-Jan-25
Location: Durham, North Carolina
Categories:
Internal Number: 253974
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina, which ranks as the number four hospital in the Raleigh-Durham, North Carolina area, accordingto U.S. News and World Report for 2023-2024. Duke Regional Hospital is the second largest of Duke Health's three hospitals and offers a comprehensive range of medical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.
Duke Nursing Highlights:
- Duke University Health System is designated as a Magnet organization
- Nurses from each hospital are consistentlyrecognized each year as North Carolina's Great 100 Nurses.
- Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
- Duke University Health System has 6000 + registered nurses
- Quality of Life: Living in the Triangle!
- Relocation Assistance (based on eligibility)
General Description of the Job Class
Contribute to the achievement of the DRH Medical Staff mission through the development and leadership of performance improvement activities in the operational and/or clinical arenas. Assure continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance.
Duties and Responsibilities of this Level
Plan activities aimed at improving the medical staff's performance in operations or clinical quality.
Identify opportunities for improved performance. Analyze data to identify adverse trends and/or undesirable performance.
Utilize performance improvement techniques and methodologies.
Work with the medical Staff to establish performance targets.
Design and implement strategies for enhancing performance.
Evaluate effectiveness of improvement strategy through sustained monitoring of performance.
Contribute to the establishment of performance improvement priorities for medical staff departments and divisions and for the organization as a whole.
Support organization's efforts to maintain compliance with regulations and accreditation standards. Monitor compliance through formal and informal processes. Recognize opportunities for improving compliance.
Design and implement strategies for enhancing compliance.
Evaluate effectiveness of improvement strategy through sustained monitoring of performance. Increase organizational understanding of performance improvement methodologies and principles and compliance through the support of and participation in formal and informal professional development activities.
Serve as an expert resource on performance improvement and compliance as it relates to medical staff role in ongoing professional performance evaluation, focused professional performance evaluation and peer review.
Produce reports and presentations on performance improvement and compliance.
Develop, maintains and enhances knowledge through orientation, self- evaluation and professional development.
Responsibilities may include varying levels of strategic planning and human and fiscal resource management.
Perform other related duties incidental to the work described herein.
Specific Duties and Responsibility of this Level will include:
- Responsible for development, implementation, coordination and performance of operational aspects of medical staff Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE) and Medical Staff Peer Review for all medical staff departments, including physicians and advanced practice providers.
- FPPE (ongoing daily/weekly process) :
- In person orientation with individual providers [pre Covid] to explain peer review processes in general and FPPE process specifically. Make recommendations for FPPE modification based on provider practice plan identified at orientation.
- Oversee the tracking of individual provider FPPE completion/delinquency, review of completed plans by dept chair and report to Credentials Committee.
- Scan FPPE plan to provider file as soon as shared with provider, then scan reviews and completed plan to provider file once complete.
- OPPE (completed Q6 months - takes up to one month to get these reports prepared and then one month to get Dept Chairs and Division Chiefs in to review and sign)
- Ongoing discussion with departments regarding meaningful metrics
- Coordination with Performance Services regarding metrics development/enhancement, comparative targets and trouble shoot any issues/questions with the same.
- Run individual provider reports from the performance services website.
- Request other data including SSI reports from IP, Cardiology registry data.
- Run Echo reports for peer review track and trend and case review patterns.
- Run Echo listing of providers to verify OPPE report for every provider who should have one.
- Match all individual reports noted above together and place signature sheet for individual review by Dept Chair/Division Chief.
- Review of the reports by clinical peer review coordinator to identify errors or aberrant data on the reports and clarify with Performance Services
- Review outlier metrics/providers and look for trend over 4 periods and/or request patient details from Performance Services.
- Once OPPE review is complete, prepare summary report for CPE, MEC, Board
- Scan completed and reviewed reports to individual provider files.
- Coordinate any enhancement plans indicated from review
- FPPE (ongoing daily/weekly process) :
- Performs daily review of SRS reports to identify cases requiring clinical review.
- Enter cases into peer review cases review, track and trend review, PACT messenger, or referral to medical staff department leaders for review, discussion and education as indicated.
- For peer review case review, screen chart and prepare case summary for first line reviewer, etc.
- Flag for review by first line reviewer.
- Once first line review complete, tag for CPE Chair review and any additional specialty review.
- Prepare letter requesting provider input as directed by CPE Chair
- Send out provider letters after review approval by CPE Chair
- Coordinate provider response including reminder notices when response not back within 15 days.
- Prepare all case documents for review by CPE Committee.
- For track and trend review, enter case details in data base, generate provider specific informational letter, and send to chair for review/approval, then send letter to provider. Scan documents to provider file.
- Prepare monthly track and trend summary for CPE review
- Identify provider trends and share with CPE/CPE-LC
- For PACT messenger cases, review patient record, if possible/indicated, review provider peer review history, prepare summary and assign messenger. Follow-up with messenger to confirm cup of coffee conversation date and notify DUHS PACT Coordinator of that date.
- Include these cases in the monthly track and trend summary for CPE review
- Identify provider trends and share with CPE/CPE-LC
- For the referral of issues to medical staff leaders, follow up for response that review discussion and potential resolution has occurred.
- Maintain manual log of cases referred to medical staff leaders/departments.
- For track and trend review, enter case details in data base, generate provider specific informational letter, and send to chair for review/approval, then send letter to provider. Scan documents to provider file.
- Performs clinical review of medical records in preparation for or in lieu of review by a physician peer reviewer, as appropriate, including preparation of case summaries.
- Enter case details and case summary in Echo peer review data base
- Flag for review by first line peer reviewer
- Follow for first line reviewer chart review completion and data entry
- Forward review to chair once first line review complete
- Generate provider inquiry letter or prepare for summary review by committee as indicated
- Coordinate response from inquiry letter to reviewed provider
- Coordinate review of response by chair and first line reviewer.
- Prepare documents for full committee review
- Performs professional objective medical record review of each case identified regarding appropriateness of patient care based on evidence-based outcomes and clinical guidelines to identify process deficits, trends and/or practice patterns. Coordinate system issues to appropriate leaders and track for response.
- Assists medical staff department and committee chairmen, and designated peer review physicians, in case review performance and documentation including providing education regarding the peer review process.
- Provide ongoing summary reports to individual providers and Medical Staff department chairmen, including provider-specific and comparative data. Prepare reports and analysis setting forth progress, adverse trends and appropriate recommendations or conclusions.
- Maintain professional knowledge of peer review requirements from external agencies, along with best practices for peer review.
- Monitor and evaluate program effectiveness, and implement modifications to improve program effectiveness as needed.
- Assist in development and implementation of policies and procedures.
- Demonstrate effective leadership skills and coordination of intra-department activities and inter-department integration. Assure the ongoing development and implementation of policies and procedures that guide and support the provision of quality OPPE, FPPE and peer review services.
- Utilizes superior discretion and ability to maintain confidential, sensitive physician peer review information, using appropriate safeguards to prevent inappropriate use or disclosure of confidential case review information.
- Identifies information needs, develops reports, and analyzes information for leaders. Provides recommendations and/or communication to appropriate leaders, teams and committees. Monitors and evaluates program effectiveness, investigates trends, and recommends and implements modifications to improve program effectiveness.
- Schedules and supports the Committee for Professional Enhancement (CPE) and the CPE - Leadership Committee. Provides support to the Committee chairs as needed.
- CPE
- Schedules meetings
- Prepares cases and reports for review by committee
- Prepares agenda for meeting and reviews with Chair
- Prepares meeting packets [with redaction for CPE] and sends out prior to meeting
- Send individual case documents to members assigned to present case to CPE
- Prepare meeting minutes
- Prepare provider inquiry and committee conclusion letters, coordinate review and approval by chair, and send out letter to individuals.
- CPE-LC
- Schedule meetings
- Prepares cases/provider trend reports for review by committee
- Prepares agenda for review by chair and sends out meeting packet
- Maintains manual log of cases/issues reviewed by LC
- Prepare communication to individual providers as indicated
- Coordinate meetings with providers as indicated
- Draft Voluntary Enhancement Plans as approved by CPE-LC
- Reach out to individual/entities working with individual providers for progress report on VEP
- Maintain VEP log and provider summary report/follow-up to CPE-LC and CPE.
- Correspond with Medical Staff Attorney as indicated for complex cases/issues.
- CPE
- May participate on other hospital or medical staff committees.
- Request/receive reports from medical staff departmental QI committees and submit to CPE
- Coordinate the DUHS PACT program at DRH based on local implementation plan.
- Assign messengers when indicated.
- Track and trend occurrences by provider
- Report cup of coffee conversation dates to DUHS
- Report provider trends to CPE-LC
- Review Press Gainey patient comment reports monthly to identify provider compliment and complaints
- Generate track and trend review in peer review data base
- Send informational letter to provider
- Report trends to CPE/CPE-LC
- Scan PG documents to MSS drive for case identification if question/concerns arise
- Scan provider track and trend documents into provider specific file.
- As indicators for peer review are retired and added, work with data base guru to develop new review template in Echo data base.
- Provide edits for template and assist with proofing and testing new template.
- Coordinate on letters and report that require edits or creation of new queries/reports
- Test new/revised letters and reports
Education:
Bachelor's degree in a business or health-related field is required.
Experience:
Minimum of 5 years work experience, including 3 years of experience with significant responsibility for performance/ process improvement. Prefer Medical Staff and/or Peer Review experience.
Degrees, Licensure, and/or Certification:
Current or compact RN licensure in the State of North Carolina required; CPHQ preferred.
Knowledge, Skills, and Abilities:
Effective written and verbal communication skills
Ability to communicate with customers/staff with diverse educational backgrounds
Analysis of data and processes for opportunities for improvement
Ability to manage numerous diverse projects simultaneously through effective priority setting, efficient use of time, organization
Knowledge of accreditation standards and regulations related to health care
Attention to detail and accuracy
Computer literacy
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.