Duke Regional Hospital Duke Regional Hospital offers the personal touch and hometown feel of a community hospital while serving as an essential arm of internationally recognized Duke University Health System. Duke Regional has served Durham, Orange, Person, Granville and Alamance counties for more than 45 years. To be successful at caring for our community and have a strong reputation among patients who seek our care, we have 3,500 team members who work together to provide exceptional, compassionate and equitable healthcare 24/7. We are a place of learning and acceptance for team members just starting their careers, as well as an institution of family culture and professional development for employees who have served for decades in our hospital units.Duke Regional has 388 inpatient beds and offers a comprehensive range of medical, surgical and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services. We also offer care at our Duke Rehabilitation Institute, Davis Ambulatory Surgical Center, Duke Ambulatory Surgery Center Arringdon, Health Services Center, and Duke Behavioral Health Center North Durham. In fiscal year 2021, Duke Regional Hospital admitted 16,422 patients, performed 18,152 surgeries and welcomed 2,673 babies into the world. U.S. News & World Report ranked Duke Regional Hospital as #9 in North Carolina and #4 in the Raleigh-Durham area for 2021-22. The Human Rights Campaign consistently names us a Healthcare Equality Leader, and we are a Joint Commission-accredited and Magnet-designated hospital.

Duke Nursing Highlights:

 

• Duke University Health System is designated as a Magnet organization
• Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
• Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000 + registered nurses
• Quality of Life: Living in the Triangle!
• Relocation Assistance!

 

Location:
Duke Regional Hospital (Medical staff Services) Durham, North Carolina 27704

 

 

Work Hours:

 Days (generally Mon-Friday from  7am-4pm) some nights /evening meetings included in work schedule.  Will consider a hybrid work schedule after 90 days.

 

 

General Description 

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. This position will report to the Medical Staff Services Manager. 

 

Duties and Responsibilities

 

• 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 and inter-department integration.  Assure the ongoing development and implementation of policies and procedures that guide and support the provision of quality OPPE, FPPE and peer review services.  
• Utilizes superior discretion and ability to maintain confidential, sensitive physician peer review information, using appropriate safeguards to prevent inappropriate use or disclosure of confidential case review information.     

 

Knowledge, Skills and Abilities

• Current or compact RN licensure in the State of North Carolina required; CPHQ or CPMSM preferred.
• 5 years of medical staff and peer review experience strongly preferred 
• Ability to communicate with customers/staff with diverse educational backgrounds
• Analysis of data and processes for opportunities for improvement
• Ability to manage numerous diverse projects simultaneously through effective priority setting, efficient use of time, organization
• Knowledge of accreditation standards and regulations related to health care
• Attention to detail and accuracy
• Computer literacy

 

Minimum Qualifications

 

 

Education

Bachelors degree in a business or health-related field is required.

 

Experience

 

Minimum of 5 years work experience, including 3 years of experience with significant responsibility for performance/ process improvement. Experience leading work teams required. Experience can be supplemented with Master's degree with a Masters being equivalent to two years of experience.

 

Degrees, Licensures, Certifications

 

 

 

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

 

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

 

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.