Physician Performance Quality Analyst
Company: Martin Memorial Health Systems, Inc.
Posted on: June 6, 2021
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The Physician Performance Quality Analyst is responsible for
assisting in the coordination of physician professional practice
evaluation process. This position supports medical staff initial
practitioner credentialing and re-credentialing process and
enhances compliance with The Joint Commission requirements for
Focused Professional Practice Evaluation (FPPE) and Ongoing
Physician Performance Evaluation (OPPE) standards. Duties include
comprehensive quality review of the medical record, abstraction,
documentation in the Hospital's quality data base and review and
analysis of clinical indicators related to practitioner medical
management and practice patterns.
Utilizing critical thinking skills and medical knowledge of
clinical care guidelines to review and analyze the appropriateness
of practitioner medical management on the basis of established
quality indicators with associated thresholds/goals and national
clinical care guidelines based on best practice
Performs professional and objective medical record review of
cases to determine appropriateness of patient care based on
evidence-based outcomes and clinical guidelines approved by the
medical staff. Entry of case summaries into the Hospital's quality
data base with ongoing monitoring and trending of the quality of
patient care related to practitioner care. Responsible for
generating a summary sheet from the Hospital;s quality data base
for review by the Chairperson of the Peer Review and the
Collects, aggregates, and displays data as requested for Peer
Review meetings, and other medical staff quality committees and
Duties may include assisting Department Chairman/Service Chiefs
and Peer Review Physician Reviewers in their review of a case by
providing support documentation and resources such as current
Policies and Procedures, Medical Staff Bylaws and Rules and
Facilitating, coordinating and performing physician performance
evaluations (ongoing and focused) in accordance with the Joint
Commission requirements. Responsibilities include generating and
mailing a Practitioner Performance Report biannually that details
the practitioner's performance related to quality of care
indicators with established acceptable thresholds and goals.
Coordinate and facilitate various quality meetings relating to
practitioner performance. Collaborates with Department Chairman,
Chief Medical Officer and Physician Peer Review Chairman to
identify process deficits, trends and/or practice patterns.
Document minutes for various meetings, compose and send
correspondence related to practitioner quality issues and utilize
Microsoft Office to document data.
Collaborate with practitioners to provide explanation regarding
quality issues, and outcomes reported via quality department
dashboards, and performance reports.
Assists in timely submission of Quality/Peer Review data to the
Patient Safety Organization.
Supports and assists the Quality Management Resources associates
to obtain documents and assemble medical staff credential quality
files, when requested.
Works collaboratively with a wide range of healthcare
professionals including providers, other healthcare leaders and
medical records personnel.
Runs reports from the Quality Data Resources for Peer Review
Committee and Credentialing Committee meetings, in addition to
individual Practitioner requests and organizational requests.
Provides education regarding quality expectations, regulatory
requirements, Ongoing Professional Practice Evaluation, Focused
Professional Practice Evaluation and Policy and Procedures to
Continually assesses and improves upon the tools and mechanisms
for which information is gathered for FPPE/OPPE activities
including indicator selection and application.
Assist as required with coordination and preparation in
anticipation of Joint Commission surveys and respond appropriately
during survey activity. Assist with the development and
implementation of plans of action for any and all applicable survey
Utilizes superior discretion and ability to maintain
confidential sensitive Physician Peer Review information. Uses
appropriate safeguards to prevent inappropriate use or disclosure
of confidential case review information.
Reviews I-Reports and enters findings into Verge database.
Performs chart reviews for peer review and disruptive behavior.
Collects data for OPPE/FPPE.
Review, track and trend mortality cases, return to surgery
cases, radiology, pathology, robotics, anesthesia, TeamHealth
reports, HIM non-compliance, surgical PA line placement, blood
management/utilization, and ED.
Review cases for requests on/from credentials, bariatric
committee, insurance review of physician quality files, corporate
compliance, and legal.
- Provides new provider orientation as needed.
To effectively fulfill the requirements of this position,
candidate must meet the following requirements:
Bachelor's Degree with a Major in Nursing, preferred;
Current/Active State of FL RN License required - primary source
online verification required directly from State of Florida
- Experience in an acute general hospital setting required.
Strong organizational, analytical and computer skills required.
Ability to act independently and exercise initiative is essential.
Possess excellent oral, written and interpersonal communication
Keywords: Martin Memorial Health Systems, Inc., Palm Beach , Physician Performance Quality Analyst, Other , Stuart, Florida
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