Under the direction of the Director the Quality/Performance Improvement specialist, the role is responsible for the development, implementation and facilitation of processes related to the peer review of cases, tracking and trending of data and maintenance of appropriate files to determine whether appropriate care was delivered in accordance with the Medical Staff Constitution, Medical Staff General Rules and Regulations, Hearing Manual, accreditation, regulatory and licensing requirements. The QI Coordinator (Case Review - CRC) applies clinical expertise and independent judgment in analyzing patient cases, identifying and pursuing presenting issues and facilitating case presentation meetings monthly to the Chief Medical Officer and Vice President of Medical Affairs.
This role leans on clinical background to review plans of care delivery, identifying and escalating potential concerns and providing consultative services and guidance to medical/legal affairs and departmental/divisional leadership as needed. CRC's exercise significant discretion in independently analyzing high-volume, time sensitive case reviews - producing legal correspondence and maintaining all required documentation/record keeping required as the case review is completed.
Primary Duties & Responsibilities
Establishes, in collaboration with Department Chairs and Clinical Chiefs, and assures that comprehensive screening and peer review criteria are maintained and consistently employed for assigned medical staff areas. Utilizes appropriate resources, literature and clinical expertise when establishing and reviewing criteria. Ensures that criteria meets regulatory, accreditation and licensing requirements.
Assures that the appropriate cases are identified and retrieved for peer review. Sets up appropriate systems to capture (i.e., using logs, special data retrieval, MIDAS, etc.) and retrieve cases.
Monitors data and peer review outcomes for any trends by MD, indicator or department and facilitates appropriate notification, review and action when trends are identified.
Coordinates and facilitates the review of cases by physicians and/or appropriate committees to determine whether appropriate care was delivered within established timeframes per department/medical staff policy. Presents findings to medical leadership, communicating essence of the case from a clinical practices perspective
Assures that peer review work sheets and electronic MIDAS worksheets are completed with appropriate codes, documentation, justification, signatures and back-up documents.
Prepares all written documentation necessary to obtain information (i.e. inquiry letters), communicate case review outcomes (i.e. educational letters), or document case review actions (follow-up letters) as needed. Assures timely response for all correspondence and documentation requests in cooperation with Department Chair and Clinical Chief.
Assures that appropriate actions are taken, documented and are in accordance with appropriate Medical Staff guidelines and/or regulatory requirements.
Performs accurate and timely data entry of peer review outcomes into the appropriate databases (i.e. MIDAS).
Creates and maintains physician profiles and files that are complete and meet department standards. Assures that all case reviews and documents are filed in the Physician?s Quality File and that the MIDAS database captures all cases reviewed.
Facilitates, creates and/or produces statistical and other reports summarizing any case review or peer review activities in accordance with standard department formats. Facilitates the production, review and presentation of Case Review Summaries to the appropriate Committees.
Facilitates the review of quality data at the time of reappointment to assess a physician competence. Assures all data and files are obtained, organized, accurate, and complete. Coordinates with Medical Staff Services to prepare and integrate information and files for review. Assists medical staff leadership in the review of the data and information and completion of appropriate documentation.
Assures that initial and focused proctoring or investigatory monitoring is performed, completed and documented in cooperation with Department Chair and Clinical Chief.
Coordinates with in-house and/or outside counsel for Fair Hearing and other hearing processes as required by case review.
Establishes and maintains uniform, organized filing system and database records. At the direction of management researches, gathers, sorts, compiles and organizes information from the files, from other departments and offices, from outside agencies, etc., for special reports and information requests.
