What are the responsibilities and job description for the Professional Practice Evaluation (PPE) Coordinator position at Bozeman Deaconess Hospital?
Position Summary:
The Professional Practice Evaluation (PPE) Coordinator participates and coordinates Bozeman Health’s collegial system-wide program of medical quality review. This position is responsible for administering the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) programs as well as coordinating the Peer Review Program in accordance with the medical staff bylaws at a system level to meet accreditation standards. This position will be responsible for preparing FPPE Scorecards at initial appointment, for additional privileges, or clinical/behavioral concerns, and OPPE Scorecards at reappointment. Develop processes to keep all applicable parties informed of trends and outcomes, capture all documentation requirements according to policy, and ensure timely communication. Responsible for managing the Clinical Professional Practice Evaluation (PPE) or Peer Review. Advance the Medical Staff peer review process in collaboration with the Medical Staff Leadership, Quality and Safety, and System Manager.
Qualifications:
- Bachelor Degree in related healthcare or business field; equivalent combination of education and experience may be considered.
- Two (2) years of related experience in medical office or health care facility including medical staff credentialing experience, familiar with FPPE/OPPE processes as related to credentialing.
Essential Job Functions: In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.
Focused Professional Practice Evaluation (FPPE) activity:
- Initiates the FPPE process on all new initial applicants, re-applicants requesting additional clinical privileges, and for any provider in need of a triggered review.
- Maintains FPPE reports in the electronic credentialing program. Keep accurate up to date FPPE log for each provider.
- Analyzes data to assess trends, performance improvement opportunities and strengths and makes recommendations as it pertains to the OPPE program.
- racks variances in required information and follows up on discrepancies and/or outstanding forms/plans, etc., ensuring deadlines are met.
- Educates providers under a FPPE as well as Department Chairs, Section Chiefs and Medical Staff Leaders and assessors of the FPPE process as needed.
- Submits completed FPPE to Department Chair for evaluation and signature. Forwards information to the Credentials/Interdisciplinary Practice Committee, Medical Executive Committee and Board of Director’s for final approval.
- Forwards notification of approval for release from FPPE to the provider via a letter from the Board of Director’s.
Ongoing Professional Practice Evaluation (OPPE) activity:
- Coordinates the policy process and execution of the OPPE program under the general supervision and guidance of the Manager of Medical Staff Services and Chief Medical Officer.
- Collaborates with Department Chairs and Section Chiefs to develop specialty specific indicators/measures, to align with OPPE standards and Hospital operations and system capabilities. Periodically reviews measures to assess feasibility, appropriateness, and achievement.
- Coordinates retrieval of indicator data with Quality Department through various Hospital sources,
- Collaborates with the Department Chair/Section Chief in analyzing data to assess for trends, performance improvement opportunities and strengths and makes recommendations as it pertains to the OPPE program.
- Copies, distributes, and files OPPE reports and any pertinent OPPE paperwork in each provider’s credential file.
- In coordination with the Manager of Medical Staff Services and Chief Medical Officer, follows up with medical staff leaders, medical staff services staff and providers to keep the OPPE process and documentation current and proceeding as necessary to meet deadlines and reporting requirements.
Peer Review activity:
- Collaborates and coordinates with the Peer Review Nurse to support an effective and continuously improving medical staff peer review program.
- Maintains information in a secure file for timely retrieval.
- Prepares reports for any trends, and for evaluation at time of reappointment or when requested by Department Chair, Section Chief or Medical Staff Leaders.
- Ensures timely communication of findings are made to providers.
- Meets department standards and turnaround times for volume of work processed and accuracy of data entered.
- Maintains minutes of all peer review meetings.
- Keeps abreast of accreditation standards in relation to FPPE, OPPE and peer review. Educates medical staff leaders, medical staff services staff and providers, fostering a commitment to compliance to these programs throughout the hospital.
Knowledge, Skills and Abilities
- Demonstrates sound judgment, patience, and maintains a professional demeanor at all times
- Exercises tact, discretion, sensitivity, and maintains confidentiality
- Performs essential job functions successfully in a busy and stressful environment
- Learns current and new computer applications and office equipment utilized at Bozeman Health
- Strong interpersonal, verbal, and written communication skills
- Analyzes, organizes, and prioritizes work while meeting multiple deadlines
Schedule Requirements
- This role requires regular and sustained attendance.
- The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.
- On-call work may be required to respond promptly to organizational, patient, or employee needs.
Physical Requirements
Lifting (Rarely – 30 pounds): Exerting force occasionally and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people.
Sit (Continuously): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain.
Stand (Occasionally): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain.
Walk (Occasionally): Walking and moving around within the work area requires good balance and coordination.
Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms.
Twist/Bend/Stoop/Kneel (Occasionally): Twisting, bending, stooping, and kneeling require flexibility and a wide range of motion in the spine and joints.
Reach Above Shoulder Level (Occasionally): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability.
Push/Pull (Occasionally): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward.
Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling.
Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials.
Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow.
Exposures (Rarely): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases due to contact with patients in areas that may have contagious illnesses.
- Frequency Key: Continuously (100% - 67% of the time), Repeatedly (66% - 33% of the time), Occasionally (32% - 4% of the time), Rarely (3% - 1% of the time), Never
The above statements are intended to describe the general nature and level of work being performed by people assigned to the job classification. They are not to be construed as a contract of any type nor an exhaustive list of all job duties performed by individuals so classified.
