This Medical Staff Performance Improvement Program Coordinator utilizes clinical, accreditation standards and quality improvement expertise to manage and coordinate the development and standardization of the medical staff performance evaluation program supporting reappointment, advancement, and clinical quality in compliance with regulatory requirements for provider performance profiles and peer review processes. The position collaborates with medical staff leadership at Northern Arizona Healthcare to develop meaningful provider specific indicators; performs chart review; monitors, measures, analyzes and reports performance data to identify variation and ensure appropriate action and improvement strategies are taken. Provides assistance to the Sr. Performance Improvement Coordinator and the Director, Medical Staff Services for medical staff departments and committees. Meetings include preparation, staffing of meeting and minutes and follow-up.
Data Integrity * Compiles performance data results into physician profiles to be reviewed periodically with Med Staff Chairs within the reappointment period. * Provides comprehensive medical record review for abstraction and analysis of indicators and validates variances in quality of care. * Responsible for the development and management of Medical Staff Performance data. * Ensures data integrity, collection, validation, trending, and reporting. |
People Management/ Staff Development * Coordinate with the Medical Staff Clinical Analyst to support the effectiveness of the NAH Medical Staff Performance Program. * Maintains knowledge of all standards and regulations involving medical staff performance data and peer review. |
Performance Management * Works with teams from Business Intelligence, Quality, Pharmacy, Pathology, Anesthesia and other clinical services, including Medical Staff department chairs, to develop appropriate provider specific metrics for performance evaluations. * Works directly with the Medical Staff Peer Review committees at FMC and VVMC in reporting, reviewing and follow-up of cases sent to committee for review assuring peer review process is functional and improves the quality of care by the medical staff. |
Department Management * Responsible for searching external databases and web sites to keep current on all data benchmarks and using data abstraction tools to produce meaningful analyses and correlation of data. * Maintains proficiency in the use of MD Staff, MIDAS, Stat-it and other databases as necessary. |
Compliance/Safety * Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner. * Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. * Completes all company mandatory modules and required job-specific training in the specified time frame. |
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