Professional Practice Evaluation Specialist, Quality Improvement

JOB SUMMARY

This paragraph summarizes the general nature, level and purpose of the job.

The PPE Specialist is responsible for the collection, entry, and integrity of clinical cases for PPE review. Facilitates the process for Medical Staff Professional Practice Evaluation at a division/departmental/service line level and integrates findings into the Hospital wide Performance Improvement Program. Facilitates compliance with Medical Staff standards as required by regulatory agencies. This role performs chart reviews and works closely with the physicians to ensure the accurate and complete documentation of PPE review triggers, causal analysis, action items, and meeting minutes. The PPE Specialist is also responsible for the administrative and scientific activities for clinical projects including clinical screening, data compilation, and documentation of all eligible patient cases.

ESSENTIAL FUNCTIONS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital's policies and procedures, including its Service Standards and its Code of Conduct.

- Monitors a variety of information for events (e.g., patient complaints, grievances, generic indicators, etc.) with potential adverse consequences for medical staff related incidents. Triages to appropriate PPE forum(s) and notifies appropriate leadership of significant events based on potential severity.
- Conducts preliminary investigation of occurrence reports, patient complaints, grievances, generic indicators, serious safety events or other event related report, as appropriate, for referral to PPE process.
- Ensures adverse events are reviewed in a timely manner. Reports significant delays in review to the appropriate administrative and medical staff leadership.
* Acts as a liaison to the Patient Safety, Medical Staff Office and Risk Management Departments. Communicates information that is relevant to potential or actual legal proceedings. Ensures that information is disseminated to appropriate staff.
- Conducts chart review and prepares case reviews for PPE Committees.
- Monitors results of PPE findings for quality and performance-related issues and trends that may indicate an opportunity to improve care; recommends actions and tracks follow-up.
- Provides data support to medical staff committees. Provide education to committee members on regulatory requirements.
- Provides staff support to Care Improvement Committee (hospital PPE committee). Prepares cases for review, ensures that notification to appropriate medical staff occurs, and ensures proper follow-up of action items.
- Reviews assigned meeting minutes for accuracy and consistency. Ensures that follow-up is done as documented.
- Participates in Ongoing Professional Practice design, data oversight, and facilitates actions base on review of data.
- Facilitates and supports medical staff leadership in the Focused PPE process.
- Develops and fosters strong cross-functional relationships and processes with clinical and administrative departments as appropriate.
- Recommends and facilitates improvement activities related to regulatory compliance.