Medical Staff Quality Analyst, Tri-City Medical Center, Oceanside, CA
Posted On February 6th, 2012
Tri-City Medical Center
Caring Hands. Our Symbol and Our Promise.
Located in the city of Oceanside, Tri-City Medical Center is a full-service healthcare facility, offering comprehensive medical care. Opened in 1961, we have grown to meet to the needs of our North County residents. We are community owned and operated, with 397 beds and over 500 physicians. Today, we are a nationally recognized hospital with a world-renowned medical and professional staff and state-of-the art technology. We have earned a reputation for highly rated, compassionate patient care.
Tri-City Medical Center serves San Diego County's coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District.
Our facilities include a hospital at 4002 Vista Way in Oceanside, nearby outpatient services, and the Tri-City Wellness Center in Carlsbad.
Position Summary:
This position is responsible for assuring the quality activities of the Medical Staff are in accordance with accreditation, regulatory and other Medical Staff requirements, including continually monitoring requirements, practices and medical staff/hospital needs for the purpose of modifying monitoring activities. Responsible to perform initial screening and analysis of reported events, conduct data abstraction, and facilitate Medical Staff meaningful case review and documentation. Implements and monitors physician specific tracking, trending and reporting. Analyzes trends and identifies key measures; acts upon trends and measures identified. Collaborates with the Medical Staff leaders to assure compliance with regulatory and accreditation requirements. Incumbent has comprehensive and advanced clinical, data analysis, and organizational skills.
Major Position Responsibilities:
- Performs analysis of reported events, initial case screening, case review data abstraction, and facilitates meaningful Medical Staff case review and documentation.
- Collaborates with hospital departments (including Operational Improvement, Service Excellence, Medical Records) to obtain aggregate and physician-specific quality measures data. Design and maintain database system for compilation and reporting in compliance with OPPE and re-appointment , incorporating identified benchmarks and comparison data..
- Analyzes reports, identifies and communicates important findings, enters results into appropriate database.
- Implements and continually monitors a physician-specific tracking, trending, and reporting processes for peer review data. Analyzes trends and identifies key measures. Communicates findings to department director and applicable medical staff leadership.
- Work with Medical Staff departments and divisions to develop, implement, monitor, and report meaningful quality review indicators that demonstrate compliance with OPPE, reappointment, and other requirements. Monitor need for updates in accordance with regulatory, accreditation changes and facility needs.
- Develops meaningful reports for departments, divisions, committees and staff and presents with analytical summary.
- Performs ad hoc audits, special studies, or other quality analysis activities and collaborates with medical staff leaders to present analytical summary.
- Collaborates with the Medical Staff leaders to assure continued compliance with regulatory and accreditation requirements.
- Applies, understands and follows Medical Staff Bylaws, Hospital Rules and Regulations, Hospital Policies and Procedures, Title 22; Joint Commission Standards, Medicare Conditions of Participation.
- Participates in other initiatives and programs and performs other duties as assigned by the Director of the department.
- Responsible to maintain confidentiality of sensitive information. Evaluates and presents information in a professional manner.
Safety and Infection Control Responsibilities
- Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
Qualifications: ESSENTIAL COMPETENCIES, KNOWLEDGE, & EXPERIENCE.
- Minimum of 3 years experience in a medical staff quality management arena of an acute care hospital, required.
- Proven expertise in organizing, analyzing, and synthesizing quantitative and qualitative data, required.
- Ability to understand and apply Medical Staff Bylaws, Hospital Rules and Regulations, Hospital Policies and Procedures; Title 22; Joint Commission Standards; and Medicare Conditions of Participation, required.
- Strong oral and written communication and interpersonal skills, required.
- Experience working with sensitive information and maintaining confidentiality, required.
- Computer proficiency in Word, Excel, PowerPoint, Outlook, required.
- Proficiency in electronic medical record systems, required. “Cerner” electronic medical record system knowledge, preferred.
- Strong computer database skills, required. “MD-Staff” computer database skills, preferred.
- Ability to work effectively in a team environment, required.
- Knowledge of regulatory and accreditation standards, required.
- Ability to manage databases and retrieve, analyze, summarize, and present information effectively, required.
Education:
- Bachelor of Science in Nursing from an accredited university, required.
- Master’s Degree, preferred.
Licenses:
CA RN License, required.
Certifications:
Certified Professional in Healthcare Quality (CPHQ) or must obtain within 12 months from hire date.
For more information about our facility, please visit www.tricitymed.org. To apply to this position, please visit www.tcmccareers.com.