CPE Coordinator/ Peer Review- Duke Regional Hospital

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

About Duke Regional Hospital

 

Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina, which ranks as the number four hospital in the Raleigh-Durham, North Carolina area, accordingto U.S. News and World Report for 2023-2024. Duke Regional Hospital is the second largest of Duke Health's three hospitals and offers a comprehensive range of medical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.

 

 

 

Occ Summary

Contribute to the achievement of the DRH Medical Staff mission through the development and leadership of performance improvement activities in the operational and/or clinical arenas. Assure continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance. 

 

 

Work Performance

 

Plan activities aimed at improving the medical staff’s performance in operations or clinical quality. Identify opportunities for improved performance. Analyze data to identify adverse trends and/or undesirable performance. Utilize performance improvement techniques and methodologies. Work with the medical Staff to establish performance targets. Design and implement strategies for enhancing performance. Evaluate effectiveness of improvement strategy through sustained monitoring of performance. Contribute to the establishment of performance improvement priorities for medical staff departments and divisions and for the organization as a whole. Support organization's efforts to maintain compliance with regulations and accreditation standards. Monitor compliance through formal and informal processes. Recognize opportunities for improving compliance. Design and implement strategies for enhancing compliance. Evaluate effectiveness of improvement strategy through sustained monitoring of performance. Increase organizational understanding of performance improvement methodologies and principles and compliance through the support of and participation in formal and informal professional development activities. Serve as an expert resource on performance improvement and compliance as it relates to medical staff role in ongoing professional performance evaluation, focused professional performance evaluation and peer review. Produce reports and presentations on performance improvement and compliance. Develop, maintains and enhances knowledge through orientation, self- evaluation and professional development. Responsibilities may include varying levels of strategic planning and human and fiscal resource management. Perform other related duties incidental to the work described herein. 

 

Specific Duties and Responsibility of this Level will include:

• Responsible for development, implementation, coordination and performance of operational aspects of medical staff Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE) and Medical Staff Peer Review for all medical staff departments, including physicians and advanced practice providers.     
• Performs daily review of SRS reports to identify cases requiring clinical review.
• Performs clinical review of medical records in preparation for or in lieu of review by a physician peer reviewer, as appropriate, including preparation of case summaries.
• Performs professional objective medical record review of each case identified regarding appropriateness of patient care based on evidence-based outcomes and clinical guidelines to identify process deficits, trends and/or practice patterns. Coordinate system issues to appropriate leaders and track for response.
• Assists medical staff department and committee chairmen, and designated peer review physicians, in case review performance and documentation including providing education regarding the peer review process.
• Provide ongoing summary reports to individual providers and Medical Staff department chairmen, including provider-specific and comparative data.  Prepare reports and analysis setting forth progress, adverse trends and appropriate recommendations or conclusions.
• Maintain professional knowledge of peer review requirements from external agencies, along with best practices for peer review.
• Monitor and evaluate program effectiveness, and implement modifications to improve program effectiveness as needed.
• Assist in development and implementation of policies and procedures.
• Demonstrate effective leadership skills and coordination of intra-department activities an