CPE / Peer Review Coordinator

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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)

Occ Summary

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. 

Work Performance

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.     
• Performs daily review of SRS reports to identify cases requiring clinical review.
• 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.
• 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.  
• 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.
• Review Press Gainey patient comment reports monthly to identify provider compliment and complaints.
• As indicators for peer review are retired and added, work with data base guru to develop new review template in Echo data base.

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, organizational. Knowledge of accreditation standards and regulations related to healthcare. Attention to detail and accuracy. Computer literacy.
 

Minimum Qualifications

Education

Bachelors degree in a business or health-related field is required.

Experience

Minimum of 3 years work experience, including experience with significant responsibility for performance/ process improvement. Prefer Medical Staff and/or Peer Review experience.

Degrees, Licensures, Certifications

Current or compact RN licensure in the State of North Carolina required; CPHQ preferred.

Distinguishing Characteristics of this Level
 
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.  

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.