Job Description

This position is responsible for the coordination, implementation and maintenance of an effective Medical Staff peerreview process and for supporting the Quality, and Risk Management program, consistent with the guidelines set forthby the Medical Staff, the Quality Services Department, and the overall Hospital Performance Improvement goals.

The Quality Outcomes Coordinator works collaboratively with the Manager of Clinical Risk and Patient Safety, othermembers of the Quality Services Department, the Medical Staff Services Department, and the Medical Staff leaders toreview and analyze referrals for peer review, and to implement, evaluate and refine a standardized PhysicianPerformance and Peer Review Program that is educational, timely, standardized, defensible, ongoing andinstrumental in assessing and improving the quality of care at AHMC Anaheim Regional Medical Center. He or sheprepares and communicates findings from focused and ongoing reviews to the appropriate Medical Staff DepartmentChairpersons and the Medical Staff Peer Review Committees.

The Quality Outcomes Coordinator assist with and ongoing data collection for the measurement, assessment, andimprovement of the clinical core measures benchmarking process. Responsibilities include supporting PerformanceImprovement Committees and Hospital Service Lines through the identification of opportunities to improve patientcare; abstracting and reviewing data for external benchmarking of core measures; assessing data for integrity andvalidity; ensuring ongoing measurement of key processes in assigned functions.This position requires the full understanding and active participation in fulfilling the mission of AHMC- AnaheimRegional Medical Center. It is expected that the employee demonstrates behavior consistent with the core values ofAHMC- ARMC and AHMC. The employee shall support AHMC- Anaheim Regional Medical Center’s strategic planand goals and direction of the performance improvement plan. The employee will also support all organizationalexpectations including, but not limited to: Customer Service, Patients’ Rights, Patient Safety, and Confidentiality ofInformation, Environment of Care, and AHMC initiatives.

Responsibilities

This position reports to the Director of Quality Services.B. Consistently applies infection control policies/practices.1. Understands and practices standard precautions for self and others in patient care activities.2. Understands and practices appropriate disease-specific isolation.C. Meets population/age specific competencies per unit specific addendum.D. Attends department specific education/training, inservices, and staff meetings.1. Attends mandatory inservices/educational/training activities.2. Submits all required paperwork on time.3. Verifies, by signature/initials, attendance at staff meetings or reading of staff meeting minutes.E. Department specific performance improvement project.1. Actively assists in unit performance improvement monitoring.2. Knows and understands Model for Improvement for Performance Improvement Program.3. Demonstrates understanding of performance improvement principles in job performance.F. Assists the Medical Staff department leadership in determining criteria for conducting ongoing professionalpractice evaluation (OPPE), triggers indicating the need for focused professional practice evaluation (FPPE),and ongoing clinical monitors.

Assists in the review and analysis referrals from unusual occurrence reports for regulatory, patient safety andpeer review concerns.H. Conducts timely, accurate concurrent and retrospective clinical case reviews by abstracting clinical data frommedical records, based on predetermined screening criteria and case referrals from Risk Management andexternal organization inquiries (i.e., regulatory and/or accrediting bodies, insurance companies, etc).I.J. Organizes, maintains and validates peer review data to ensure data completeness, validity and integrity on anongoing basis to support medical staff performance improvement and patient safety organizational activities.K. Participates in medical staff peer review committees as required.L.M. Assist Risk Manager in the review and analysis of incoming Risk Management occurrence reports, especiallythose related to physician practices.N. Ensures proper function of the Risk Management and Medical Staff Peer Review process.1. Ensures comprehensive screening according to peer review criteria is conducted.2. Coordinates the identification and retrieval of cases from unusual occurrence reports and other sources.3. Coordinates and facilitates the review of cases by physicians.4. Creates and produces statistical and other reports summarizing peer review activities.O.P. Participates in the design and development of efficient procedures for accurate clinical data extraction, dataentry, and reporting of clinical indicators and outcomes as determined by internal and external reportingrequirements.Q. Supports Quality Department PI PI Manager in continuous validation and inter-reliability studies asdetermined by director, quality services.1. Research and reporting to include appropriate internal and external benchmarks.R. Maintains and applies knowledge of accreditation and licensing standards pertinent to improvingorganizational performance.1. Provides education to medical staff and hospital departments on quality standards affecting their areas ofresponsibility.2. Participates in accreditation surveys and provides follow-up recommendations for improvement oforganizational performance.S. Maintains monitoring systems to assess compliance with established clinical policies, core measurealgorithms, patient care standards, and rules and regulations affecting quality of patient care.T. Follows policies and systems for monitoring, validating, documenting, and reporting quality improvement data.U. Networks effectively with various individuals and groups to guide their activities toward achievement ofAHMC/ARMC, and departmental quality and clinical goals.V. ADDITIONAL JOB RESPONSIBILITIES: As assigned by the Director of Quality Services.

Qualifications

Clinical degree (LVN, BA, BSN, or BS or Associates Degree) preferred. Current CA RN license preferred. Minimum of 2 years in performance improvement, case management, risk management or decision supportfunctions preferred; may be met by minimum of 3 years in healthcare business office/admitting setting. Experiential focus on monitoring and evaluation of operational processes in order to meet state, federal andother regulatory agency requirements. Ability to perform technical analysis of patient records, abstract pertinent information and prepare and presentclinical information in such a manner as to highlight statistical significance and relevance. Comprehensive knowledge of The Joint Commission standards and Title 22 requirements Ability to perform technical abstraction of patient records by abstracting pertinent information andpreparing/presenting clinical information in such a manner as to highlight discrepancies in data. Ability to address multiple tasks that frequently have short timelines. Ability to work independently. Ability to maintain current and accurate databases and files. Ability to communicate effectively in both the written and verbal format. Basic typing and computer proficiency in Microsoft Office and google workspace d MicroMed applications.

About AHMC HealthCare

6-Hospital Health Care System.

Located in the Greater San Gabriel Valley area, AHMC consists of 6 comprehensive acute care facilities.•1,023 total beds

•Over 6,500 employees

•Over 2,500 physicians

•Over 76,000 patients seek care through our ERs

•Over 200,000 total patients treated annually

AHMC is committed to providing the highest quality, most compassionate care for our community.

Industry

Healthcare & Social Services

Company Size

1,001-5,000 employees

Headquarters

Unknown

Year Founded

Unknown

Website

ahmchealth.com

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