Medical Staff RN Quality Coordinator

Why ThedaCare?   

Living A Life Inspired!

Our new vision at ThedaCare is bold, ambitious, and ignited by a shared passion to provide outstanding care. We are inspired to reinvent health care by becoming a proactive partner in health, enriching the lives of all and creating value in everything we do. Each of us are called to take action in delivering higher standards of care, lower costs and a healthier future for our patients, our families, our communities and our world. 

At ThedaCare, our team members are empowered to be the catalyst of change through our values of compassion, excellence, leadership, innovation, and agility.  A career means much more than excellent compensation and benefits. Our team members are supported by continued opportunities for learning and development, accessible and transparent leadership, and a commitment to work/life balance. If you’re interested in joining a health care system that is changing the face of care and well-being in our community, we encourage you to explore a future with ThedaCare.

Benefits, with a whole-person approach to wellness –

• Lifestyle Engagement
  • e.g. health coaches, relaxation rooms, health focused apps (Wonder, Ripple), mental health support  

• Access & Affordability
  • e.g. minimal or zero copays, team member cost sharing premiums, daycare

About ThedaCare!

Summary :

The Medical Staff RN Quality Coordinator plans, prioritzes, implements, and coordinates projects related to provider quality, compliance and regulatory requirements. Facilitates the coordination of provider data analysis and improvement activities including Ongoing Professional Practice Evaluation (OPPE), Focused Professinal Practice Evalation (FPPE), and Peer Review cases. Interprets, evaluates, and reports data to improve quality and patient care outcomes using problem solving tooks to identify potential areas of improvement.
Monitors all aspects of the process to ensure compliance with regulatory and Joint Commission standards and Medical Staff Bylaws.

Job Description:

Key Accountabilities

• Collaborates with the Medical Staff department to develop and distribute quality data for the Focused Professional Practice Evaluation (FPPE) process and the Ongoing Professional Practice Evaluation (OPPE) according to regulatory requirements, accreditation standards, state and federal laws, and Medical Staff bylaws.

• Researches and recommends FPPE criteria and ensures that all new applicants undergo FPPE within established timeframes, following up with proctors and/or reviewers as necessary.

• Coordinates the provider’s Ongoing Professional Practice Evaluation (OPPE) process including performing and preparing reports on initial clinical assessments for medical staff leaders. 

• Collaborates with medical staff leaders in reviewing OPPE and identifying provider performance events within their departments and facilitating next steps to evaluate and drive improvement in individual provider performance.

• Analyzes, monitors, and reports on compliance and outcomes of provider quality indicators  

• Assists with preparation of quarterly peer review reports that are reported up to appropriate System committees.

• Coordinates focus studies and researches medical literature when necessary to evaluate quality of care.

• Coordinates and attends Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review.   

• Oversees physician peer review data is entered in the appropriate database in a timely and accurate manner.

• Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications

• Assists with the development and coordination of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program.

• Maintain continuous knowledge of Joint Commission and other regulatory standards/regulations, Medical Staff Bylaws and organizational policies and procedures pertaining to provider performance and peer review process Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing

• Promote individual professional growth and development by meeting requirements for mandatory/continuing educatio