This position is responsible for the coordination, implementation and maintenance of an effective Medical Staff peer
review process and for supporting the Quality, and Risk Management program, consistent with the guidelines set forth
by the Medical Staff, the Quality Services Department, and the overall Hospital Performance Improvement goals.
The Quality Outcomes Coordinator works collaboratively with the Manager of Clinical Risk and Patient Safety, other
members of the Quality Services Department, the Medical Staff Services Department, and the Medical Staff leaders to
review and analyze referrals for peer review, and to implement, evaluate and refine a standardized Physician
Performance and Peer Review Program that is educational, timely, standardized, defensible, ongoing and
instrumental in assessing and improving the quality of care at AHMC Anaheim Regional Medical Center. He or she
prepares and communicates findings from focused and ongoing reviews to the appropriate Medical Staff Department
Chairpersons and the Medical Staff Peer Review Committees.
The Quality Outcomes Coordinator assist with and ongoing data collection for the measurement, assessment, and
improvement of the clinical core measures benchmarking process. Responsibilities include supporting Performance
Improvement Committees and Hospital Service Lines through the identification of opportunities to improve patient
care; abstracting and reviewing data for external benchmarking of core measures; assessing data for integrity and
validity; ensuring ongoing measurement of key processes in assigned functions.
This position requires the full understanding and active participation in fulfilling the mission of AHMC- Anaheim
Regional Medical Center. It is expected that the employee demonstrates behavior consistent with the core values of
AHMC- ARMC and AHMC. The employee shall support AHMC- Anaheim Regional Medical Center’s strategic plan
and goals and direction of the performance improvement plan. The employee will also support all organizational
expectations including, but not limited to: Customer Service, Patients’ Rights, Patient Safety, and Confidentiality of
Information, Environment of Care, and AHMC initiatives.
B. Consistently applies infection control policies/practices.
1. Understands and practices standard precautions for self and others in patient care activities.
2. Understands and practices appropriate disease-specific isolation.
C. Meets population/age specific competencies per unit specific addendum.
D. Attends department specific education/training, inservices, and staff meetings.
1. Attends mandatory inservices/educational/training activities.
2. Submits all required paperwork on time.
3. Verifies, by signature/initials, attendance at staff meetings or reading of staff meeting minutes.
E. Department specific performance improvement project.
1. Actively assists in unit performance improvement monitoring.
2. Knows and understands Model for Improvement for Performance Improvement Program.
3. Demonstrates understanding of performance improvement principles in job performance.
F. Assists the Medical Staff department leadership in determining criteria for conducting ongoing professional
practice evaluation (OPPE), triggers indicating the need for focused professional practice evaluation (FPPE),
and ongoing clinical monitors. Assists in the review and analysis referrals from unusual occurrence reports for regulatory, patient safety and
peer review concerns.
H. Conducts timely, accurate concurrent and retrospective clinical case reviews by abstracting clinical data from
medical records, based on predetermined screening criteria and case referrals from Risk Management and
external organization inquiries (i.e., regulatory and/or accrediting bodies, insurance companies, etc).
I.
J. Organizes, maintains and validates peer review data to ensure data completeness, validity and integrity on an
ongoing basis to support medical staff performance improvement and patient safety organizational activities.
K. Participates in medical staff peer review committees as required.
L.
M. Assist Risk Manager in the review and analysis of incoming Risk Management occurrence reports, especially
those related to physician practices.
N. Ensures proper function of the Risk Management and Medical Staff Peer Review process.
1. Ensures comprehensive screening according to peer review criteria is conducted.
2. Coordinates the identification and retrieval of cases from unusual occurrence reports and other sources.
3. Coordinates and facilitates the review of cases by physicians.
4. Creates and produces statistical and other reports summarizing peer review activities.
O.
P. Participates in the design and development of efficient procedures for accurate clinical data extraction, data
entry, and reporting of clinical indicators and outcomes as determined by internal and external reporting
requirements.
Q. Supports Quality Department PI PI Manager in continuous validation and inter-reliability studies as
determined by director, quality services.
1. Research and reporting to include appropriate internal and external benchmarks.
R. Maintains and applies knowledge of accreditation and licensing standards pertinent to improving
organizational performance.
1. Provides education to medical staff and hospital departments on quality standards affecting their areas of
responsibility.
2. Participates in accreditation surveys and provides follow-up recommendations for improvement of
organizational performance.
S. Maintains monitoring systems to assess compliance with established clinical policies, core measure
algorithms, patient care standards, and rules and regulations affecting quality of patient care.
T. Follows policies and systems for monitoring, validating, documenting, and reporting quality improvement data.
U. Networks effectively with various individuals and groups to guide their activities toward achievement of
AHMC/ARMC, and departmental quality and clinical goals.
V. ADDITIONAL JOB RESPONSIBILITIES: As assigned by the Director of Quality Services.
Qualifications
Clinical degree (LVN, BA, BSN, or BS or Associates Degree) preferred.
Current CA RN license preferred.
Minimum of 2 years in performance improvement, case management, risk management or decision support
functions preferred; may be met by minimum of 3 years in healthcare business office/admitting setting.
Experiential focus on monitoring and evaluation of operational processes in order to meet state, federal and
other regulatory agency requirements.
Ability to perform technical analysis of patient records, abstract pertinent information and prepare and present
clinical information in such a manner as to highlight statistical significance and relevance.
Comprehensive knowledge of The Joint Commission standards and Title 22 requirements
Ability to perform technical abstraction of patient records by abstracting pertinent information and
preparing/presenting clinical information in such a manner as to highlight discrepancies in data.
Ability to address multiple tasks that frequently have short timelines.
Ability to work independently.
Ability to maintain current and accurate databases and files.
Ability to communicate effectively in both the written and verbal format.
Basic typing and computer proficiency in Microsoft Office and google workspace d MicroMed applications.
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