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This job is responsible for coordinating and overseeing multiple Virginia Mason Franciscan Health (VMFH) medical staff peer review programs and for supporting the activities of the medical staff processes related to the Ongoing Professional Practice Evaluations (OPPE) and the Focused Professional Practice Evaluations (FPPE) for practitioners who have been granted clinical privileges. Peer review is instrumental in identifying, tracking and supporting the resolution of clinical performance and/or professional conduct issues in a manner that promotes education, quality improvement and patient safety.

Work involves the support of OPPE and FPPE decision-making processes that are designed to facilitate high quality and safe patient safety initiatives, assure compliance with evidence-based patient care standards, applicable regulatory requirements and promote systemic improvements as defined by The Joint Commission, Centers for Medicare and Medicaid Services and other applicable regulatory bodies. An incumbent oversees the collection and analyses of Quality Indicators and Occurrence Screen data from multiple sources to aggregate data that identifies trends indicating both high quality outcomes as well as trends that indicate substandard outcomes to facilitate quality improvement opportunities for the Medical staff. Work also includes: 1) working with provider teams to support/assist with improvements in provider performance and documentation; 2) overseeing the digitalization and subsequent maintenance of all provider files; and 3) overseeing the work of peer review staff.

Work requires knowledge of peer review systems, standards, processes and regulatory requirements as well as effective methodologies for screening performance against established quality indicators and preparing timely and effective case studies for presentation to medical staff committees. Also requires proficiency in oversight of data collection, analysis, interpretation and presentation to high-level audiences and physician groups. An incumbent is responsible for keeping abreast of current/changing regulatory requirements with potential to impact documentation practices and related training.

Education/Work Experience Requirements:
Bachelor’s degree in healthcare administration, nursing or other related discipline, graduation from an accredited school of nursing, and five years of related work experience that would demonstrate attainment of the requisite job knowledge/abilities.

Licensure/Certification:
Current licensure as a Registered Nurse by the Washington State Nursing Commission.

In 2020 united in a fierce commitment to deliver the highest quality care and exceptional patient experience Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care including 11 hospitals and nearly 5000 physicians and providers. Together we are empowered to make an even greater impact on the health and well-being of our communities.