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

Keck Medicine of USC; Arcadia (CA); On-site; USD 80,000 - 100,000; Full time

Job summary

Keck Medicine of USC in Arcadia is searching for a Quality Performance Improvement Specialist responsible for coordinating organization-wide quality improvement activities aimed at enhancing patient outcomes and safety. This role involves close collaboration with Medical Staff leadership to provide accurate clinical data, conduct chart reviews, and analyze data trends to meet regulatory compliance.

The ideal candidate must possess a Bachelor of Science in Nursing along with a current RN license in California and have at least five years of clinical experience. This position offers an opportunity to make impactful contributions to patient care quality and safety.

Qualifications

• Minimum of five years of clinical experience, preferably in medical/surgical or critical care.
• Current RN licensure in California.
• Experience with quality and performance improvement preferred.

Responsibilities

• Support and coordinate quality/performance improvement activities.
• Conduct chart reviews and collect data for quality measures.
• Collaborate with Medical Staff leadership for data analysis.

Skills

Communication

Problem Solving

Project Management

Interpersonal Skills

Education

Bachelor of Science in Nursing

Job description

Essential Job Functions and Core 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, and communicates decisions to others. Escalates issues that do not conform to established expectations to the Director. Maintains confidentiality and protects sensitive data.
• Computer Skills: Skilled in the use of computers, adapts to new technology, keeps abreast of changes, learns new programs quickly, and 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 independently, seeks out new responsibilities, acts on opportunities, generates new ideas, and 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 team members. Collaborates effectively and appropriately with Medical Staff Leadership and members.
• Job Knowledge: Understands duties and responsibilities, has necessary technical skills, keeps job knowledge current, and 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 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 (core measures, AHRQ Patient Safety Indicators, Hospital Acquired Conditions).
• Personal Organization: Keeps information organized and accessible, maintains a clean functional workspace, works systematically and efficiently, and manages time well.
• Problem Solving/Analysis: Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, and distinguishes critical details from unimportant facts. Meets with physicians, nursing and ancillary staff and leaders to determine root cause/barrier to compliance and formulate performance improvement strategies. Considers age‑specific and cultural issues in problem‑solving. 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 effective procedures, and manages time well. Handles information flow and ensures needed data is collected on a timely basis. Reports progress regularly and ensures timely reporting of required issues/items to 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 resources, coordinates projects throughout the company, monitors progress, and manages multiple projects. Participates in or coordinates multidisciplinary 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 are 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, and 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 to a minimum and are not repetitive in nature.
• Other duties, as assigned.

Job Requirements

Education

• Minimum (Required): Bachelor of Science in Nursing

Work Experience

• Minimum (Required): A minimum of five years of clinical experience is required with a preference for medical/surgical or critical care focus.
• Preferred (Not Required): Two years of Quality/Performance Improvement experience.

Licenses and Certifications

• Minimum (Required): A current RN licensure in the State of California is required.
• Preferred (Not Required): Certified Professional in Healthcare Quality (CPHQ) preferred.

Position Summary

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 with 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 assurance that the hospital adheres 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.