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Employment Type:

Full time

Shift:

Description:

The Medical Staff Quality Assurance Specialist provides clinical support for the medical staff peer review process to ensure maintenance of the highest standards related to practitioner competency, clinical excellence, patient safety and compliance with medical staff policies, rules & regulations, bylaws and accreditation standards. Through clinical data collection/abstraction, data analysis, reporting, and in-depth clinical review of cases identified for peer review identifying patterns or trends related to patient safety and quality of care, coordinates quality assurance activities, monitors performance metrics, and implements improvement initiatives to enhance patient care and safety. Interprets and implements quality assurance standards to ensure quality of care for patients and ensures alignment with medical staff and organizational policies, and regulatory and legal requirements. This position collaborates and participates in the peer review process to support physician leaders with quality assurance efforts and the identification of performance improvement opportunities to enhance patient safety and clinical outcomes.

Position Summary:

The Medical Staff Quality Assurance Specialist provides clinical support for the medical staff peer review process to ensure maintenance of the highest standards related to practitioner competency, clinical excellence, patient safety and compliance with medical staff policies, rules & regulations, bylaws and accreditation standards. Through clinical data collection/abstraction, data analysis, reporting, and in-depth clinical review of cases identified for peer review identifying patterns or trends related to patient safety and quality of care, coordinates quality assurance activities, monitors performance metrics, and implements improvement initiatives to enhance patient care and safety. Interprets and implements quality assurance standards to ensure quality of care for patients and ensures alignment with medical staff and organizational policies, and regulatory and legal requirements. This position collaborates and participates in the peer review process to support physician leaders with quality assurance efforts and the identification of performance improvement opportunities to enhance patient safety and clinical outcomes.

What the Quality Assurance Specialist will need:

+ Bachelor’s degree in a health care field; or an equivalent combination of education and experience.

+ Licensed to practice as a Registered Nurse in the State of Michigan

+ Experience collecting, analyzing, and managing clinical data and information.

+ Knowledge of process improvement tools and techniques.

+ Experience managing clinical quality, core measures, and Joint Commission requirements with demonstrated understanding of CMS, Joint Commission standards.

+ Experience collaborating with interdisciplinary teams and physician leaders to develop and implement quality improvement initiatives aimed at enhancing patient safety and clinical outcomes.

What the Quality Assurance Specialist will do:

+ **Our Trinity Health Culture:** Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.

+ **Quality Assurance:** Conducts concurrent quality assurance reviews - Reviews medical records for quality assurance and compliance with evidence-based medicine requirements, regularly audits and reviews medical staff practices to ensure adherence to established standards and protocols. Performs routine and in-depth medical record review, analysis and audits to evaluate events and significant issues to determine if a case meets medical staff criteria for peer review, to address clinical care concerns identified in the peer review process and identify improvement opportunities.

+ **Performance Monitoring:** Monitor and analyze performance metrics, clinical outcomes, and compliance with regulatory standards. Identifies variances in the quality of care – trends, analyzes, and interprets clinical performance data - provides appropriate feedback. Demonstrates knowledge of clinical documentation requirements with the ability to interpret and synthesize complex clinical concepts and apply knowledge of medical staff, including clinical practice guidelines and policies in the concurrent or retrospective review of patient medical records.

+ **Process Improvement:** Collaborates with physician leaders to identify concerns related to the quality of patient care and patient safety. Collaborates with other areas to improve the flow of information and quality data into the peer review processes. In coordination with medical staff and administrative leadership, develops, designs, and recommend strategies/initiatives to improve performance in clinical quality, patient safety, and regulatory compliance for all medical staff.

+ **Data Collection and Analysis:** Collect and analyze data related to medical staff performance, patient outcomes, and quality improvement initiatives. Uses appropriate computer applications in abstraction and data analysis to identify patterns or trends related to patient safety and quality of care for the facilitation of data-based decisions and process improvement.

+ **Professional Practice Evaluations (PPE):** Assists in the maintenance of an efficient and effective program for management of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) for cause tracking, evaluation and follow up.

+ **Training and Education:** Provide training and education to medical staff and administrative colleagues on quality assurance processes, best practices, organizational and regulatory requirements.

+ **Regulatory Compliance:** Ensure compliance with all relevant regulatory requirements, accreditation standards, and organizational policies. Facilitates ongoing preparedness for accreditation and regulatory agencies. Reviews quality assurance standards, studies existing hospital policies and procedures, and conducts quality audits and evaluates effectiveness of the medical staff quality assurance program. Reviews, audits, and monitors peer review program compliance with required CMS, Joint Commission requirements. Reviews and validates clinical data/indicators according to evidence-based medicine, organizational, medical staff, CMS, and Joint Commission standards.

+ **Policies & Procedures:** Assists in the development of policies and procedures related to medical staff peer review. Interprets and educates stakeholders. Serves as a resource regarding medical staff peer review processes, procedures, and requirements.

+ **Champion and change agent for quality and safety:** Appropriately challenges current processes, policies and procedures. Seeks to incorporate new technologies and methods to improve overall effectiveness. Seeks multidisciplinary expertise as necessary to solve problems and stay ahead of process developments. Facilitates own personal professional development through participation in educational programs, in-service meetings and workshops and by reading current literature.

+ Actively participates in committees and task forces as directed.

+ Performs other related assignments as directed.

+ **Maintains a working knowledge** of applicable Federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of conduct, as well as other policies & procedures in order to ensure adherence in a manner that reflects honest, ethical & professional behavior.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran