Peer Review Nurse - Quality Management

CHRISTUS Santa Rosa Hospital - New Braunfels (CSRH-NB), nestled in the heart of downtown New Braunfels, is a full-service, 94-private bed facility that continues to expand to meet the needs of New Braunfels’ strong population growth. Innovative equipment and procedures are utilized, including an Outpatient Imaging Center, orthopedic and surgical services, rehabilitation, a renovated birthing center, including 24/7 neonatal coverage, emergency care, wound care/hyperbaric center, 3D mammography, and comprehensive heart care, from diagnostics to open-heart surgery.  

Summary:

In a High Reliability Organization, the Peer Review Nurse, reporting to the Director of Quality, is responsible for organizing and coordinating Medical Staff Peer Review activities of hospital. This individual, as a designee of the Chief Medical Officers, will demonstrate their expertise in quality management through performance of medical staff screening to determine whether a referred case meets criteria for Peer Review Committee review. Organizes, prepares, schedules, and records minutes of the Medical Staff Peer Review Committee. Assist with data presentation, staff understanding of aggregated data, and ensuring minutes/follow-up is done in a timely manner. This role is expected to apply clinical knowledge and analytical skills to assist the Director of QM and Chief Medical Officer to support change with a strong focus on improving quality outcomes and results.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Communicate effectively to different audiences.
• Proficient in computer skills using EXCEL, PowerPoint, MS Office, and Flowchart tools.
• Knowledgeable on High-Reliability Principles and PDSA methodology.

Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains

• Quality Leadership and Integration- Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Proficient.
• Performance and Process Improvement- Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Foundational.
• Population Health and Care Transitions- Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Foundational.
• Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Foundational.
• Regulatory and Accreditation- Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation and certification surveys and activities. Domain Level: Foundational.
• Patients Safety- Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Proficient.
• Quality Review and Accountability- Direct activities that support compliance with organization wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Foundational.
• Professional Engagement- Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Foundational.

Job Requirements:

Education/Skills

• Associate degree in nursing required.
• Bachelor's degree preferred.

Experience

• Three years of healthcare experience.
• Two years of quality management experience preferred.

Licenses, Registrations, or Certifications

• CPHQ (Certified Professional in Healthcare Quality) preferred.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time