PI/Peer Review Coordinator - Performance Improvement - Full time 10 hours Days (Non-Union, Exempt)

Keck Medicine of USC

6d•$49 - $73

About The Position

Responsible for supporting and coordinating the assigned, organization-wide quality/performance improvement activities designed to improve patient outcomes and patient safety, in support of the hospital Performance Improvement Program. Supports the Medical Staff Peer Review Committee functions and the flow of information to Medical Staff groups and hospital departments. This role works closely with Medical Staff leadership on providing accurate clinical summaries, data trending, reports, and analyses. Performs chart reviews and abstracts data for quality and patient safety initiatives, such as core and quality measures, to determine compliance Federal and State regulatory requirements and Joint Commission standards. Collects, aggregates, analyzes, and reviews data for improvement opportunities. Collaborates with coworkers, staff, hospital leaders, and Medical Staff to achieve compliance and improvement with hospital initiatives. Assists and supports the Director or Manager of Quality/Performance Improvement, Administration, and the Medical Staff in fulfilling related responsibilities and reporting requirements. Provides evaluation, updating and assuring hospital adherence to established and newly implemented policies and procedures from recognized regulatory agencies. Works closely with the organized medical staff to fulfill their responsibilities of maintaining the quality of patient outcomes. USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance, and with due consideration for patient and student safety. Please refer to the Background Screening Policy Appendix D for specific employment screen implications for the position for which you are applying. We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at [email protected]. Inquiries will be treated as confidential to the extent permitted by law. Notice of Non-discrimination Employment Equity Read USC’s Clery Act Annual Security Report USC is a smoke-free environment Digital Accessibility If you are a current USC employee, please apply to this USC job posting in Workday by copying and pasting this link into your browser: https://wd5.myworkday.com/usc/d/inst/1$9925/9925$140870.htmld Keck Medicine of USC is the University of Southern California’s medical enterprise, one of only two university-based medical systems in the Los Angeles area. Keck Medicine combines academic excellence, world-class research and state-of-the-art facilities to provide highly specialized care for some of the most acute patients in the country. Our internationally renowned physicians and scientists provide world-class patient care at Keck Hospital of USC, USC Norris Cancer Hospital, USC Verdugo Hills Hospital, USC Arcadia Hospital and more than 100 unique clinics in Los Angeles, Orange, Kern, Tulare and Ventura counties. Keck Medical Center of USC, which includes Keck Hospital and USC Norris Cancer Hospital, is among the top 50 hospitals in the country in 8 specialties, as well as the top three hospitals in metro Los Angeles and top 10 hospitals in California, according to U.S. News & World Report’s 2024-25 Best Hospitals rankings. Application Help & Benefits If you need help during the application process, see our application help. For more information about our benefits, see What We Offer. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

Requirements

Bachelor of Science in Nursing
A minimum of five years of clinical experience is required with a preference for medical/surgical or critical care focus.
A current RN licensure in the State of California is required.

Nice To Haves

Two years of Quality/Performance Improvement experience preferred.
Certified Professional in Healthcare Quality (CPHQ) preferred

Responsibilities

Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others. Demonstrates exceptional customer service and interacts effectively with physicians, staff, leaders, and the broader health care community.
Decision-Making/Judgment: Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus, when possible, communicates decisions to others. Escalates issues that do not conform to established expectations to the Director. Maintains confidentiality and always protects sensitive data.
Computer Skills: Skilled in the use of computers, adapts to new technology, keeps abreast of changes, learns new programs quickly, uses computers to improve productivity.
Initiative: Searches out and communicates best performance and quality improvement practices. Identifies and recommends corrective action plans for implementation when indicator measurement is below target. Tackles problems and takes independent action, seeks out new responsibilities, acts on opportunities, generates new ideas, practices self-development. At least 50% of CEUs are related to performance improvement, patient safety and/or peer review subject matter.
Interpersonal Skills: Has effective active listening skills, builds strong relationships, is flexible/open-minded, negotiates effectively, solicits performance feedback, and handles constructive criticism. Works collaboratively and supports efforts of team members. Collaborates effectively, efficiently, and appropriately with Medical Staff Leadership and members.
Job Knowledge: Understands duties and responsibilities, has job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. Serves as a resource for standards of care and practice related to patient care and safety and staff safety. Maintains expertise in data definitions for external reporting. Identifies cases meeting the criteria for clinical case review. Performs RN level of retrospective morbidity and mortality review using indicators and screening criteria. Conducts detailed medical records reviews for peer review, as appropriate. Maintains knowledge of evidence-based, CMS/CDPH and Joint Commission clinical metrics (i.e., core measures, AHRQ Patient Safety Indicators, Hospital Acquired Conditions).
Personal Organization: Keeps information organized and accessible, maintains clean/functional workspace, works systematically and efficiently, manages time well.
Problem Solving/Analysis: Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. Meets with physicians, nursing and ancillary staff and leaders to determine the root cause/barrier to compliance and formulate performance improvement strategies. Considers age-specific and cultural issues in problem-solving case specific issues. Applies statistical tools to determine root causes of identified problems including flowcharts, trending forms, bar graphs and control charts. Understands statistical variation: common cause versus special cause and uses it to focus corrective actions.
Productivity: Manages workload, prioritizes tasks, develops good work procedures, manages time well, handles information flow. Ensures needed data is collected on a timely basis and reports on progress are regularly distributed. Manages workload, prioritizes tasks, develops effective, efficient procedures that minimize waste. Ensures the timely reporting of required issues/items to both external agencies, the Peer Review Committee, Quality Committees, PI related Committees, and the Director or Manager of Quality/Performance Improvement.
Project Management: Establishes project goals, milestones, and procedures, defines roles and responsibilities, acquires project resources, coordinates projects throughout company, monitors project progress, manages multiple projects. Participates in or coordinates multi-disciplinary PI teams to support key quality and patient safety initiatives. Supports or coordinates the following projects as assigned: Core Measures and related inter-rater reliability, reporting and improvement; peer review; mortality review, and other priorities as established in the annual PI and Patient Safety plans. Ensures the relevant findings, conclusions and recommendations resulting from the Peer Review system is reported as required.
Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, recognizes and acts on quality problems. Data results are validated prior to presentation and/or submission to external agencies. Reference sources are easily retrieved and available. The information provided is concise yet thorough. Corrections to work product are kept at a minimum and not repetitive in nature.
Other duties, as assigned.