Job Overview

This position is responsible for overseeing the quality improvement initiatives, regulatory compliance, and patient safety aspects of the Transplant Program. Focuses on enhancing overall program performance by identifying opportunities for improvement, developing performance indicators, and implementing corrective action plans based on survey findings and data analysis. This position collaborates closely with key stakeholders, peers, and other departments to foster a culture of safety and quality, ensuring adherence to regulatory standards. This position is critical for maintaining the integrity of the Transplant Program and advancing the organization's mission to provide exceptional patient care.

Job Description

Minimum Qualifications:

1. Master's degree in Nursing, Healthcare Administration, Public Health, or a related health science field OR;

Bachelor's degree in Nursing, Public Health, or a related field AND Eight (8) years of related experience in quality and regulatory functions within a healthcare setting.

Preferred Qualification:

1. Quality and Regulatory experience.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Oversees and coordinates efforts related to the Transplant Program Clinical Quality and Patient Safety Performance Improvement Program.

2. Facilitates the identification of opportunities for improvement and assists in the design and ongoing measurement of performance indicators and outcomes.

3. Collaborates with key stakeholders and other departments to facilitate and monitor the timely completion of corrective action plans resulting from survey findings, root cause analyses, or other sources.

4. Plans, coordinates, and reports Adverse Event Reviews for solid organ transplant and VAD services.

5. Partners with physician leadership and the Department of Surgery to coordinate Transplant Mortality and Morbidity conferences.

6. Facilitates and participates in improvement initiatives related to the Transplant Program and VAD services as appropriate.

7. Monitors and maintains current transplant policies and guidelines for Heart, Kidney, Liver, and VAD services.

8. Supports an information system for quality and regulatory management data collection, aggregation, and analysis, maintaining an inventory of quality improvement activities, including safety measures of success.

9. Monitors and displays statistical data for quality reports and evaluations.

10. Serves as an internal resource for the quality and performance improvement processes, including data measurement, tool development, chart reviews, improvement strategies, and education on methodologies.

11. Collaborates with the Data and Informatics Administrator to ensure accurate Epic dashboards are available and reviewed.

12. Reviews monthly XYN QAPI data and provide summaries at monthly organ-specific QAPI meetings.

13. Collaborates with the Data and Informatics Administrator to review SRTR data releases and ensure timely communication of information to the transplant program.

14. Utilizes knowledge of accreditation standards and regulatory agencies to assist with compliance assessments, engaging staff through observation, interviews, and medical record reviews.

15. Participates in the preparation, planning, coordination, and oversight of planned and unplanned regulatory surveys and reporting by The Joint Commission, DPH, CMS, UNOS, and other regulatory agencies.

16. Monitors changes in CMS and UNOS regulations regarding solid organ transplant services, assess the impact of policy changes, and collaborate with stakeholders to develop implementation and monitoring plans.

Physical Requirements:

1. Normal office setting.

2. Frequent contact with patients, medical staff, and department personnel.

3. Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.

4. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

5. Requires ability to see computer screen and reports.

Skills & Abilities:

1. Strong knowledge of quality improvement processes and regulatory compliance in a healthcare setting.

2. Excellent management, leadership, and interpersonal skills for effective oversight of quality and regulatory initiatives.

3. Familiarity with data collection, aggregation, and analysis methodologies related to healthcare quality and safety.

4. Strong analytical skills, with the ability to interpret clinical data and quality metrics.

5. Excellent communication skills, both verbal and written, with the ability to present information effectively to diverse audiences.

6. Ability to manage multiple projects simultaneously and prioritize effectively.

7. Highly resourceful team player who can effectively collaborate with staff and senior leadership.

8. Ability to define problems, collect data, establish facts, and draw valid conclusions.

9. Proficient in using healthcare data systems and software applications for quality management.

Job Profile Summary

This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. In addition, this role focuses on performing the following Quality Leadership duties: Controls, directs, and participates in the activities of the organization through a hierarchy of managers and supervisors. Responsibilities also include long-term strategic planning, determining the policies of the organization, and allocating its resources and making decisions regarding organization growth and diversification to accomplish entity's vision. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that manages experienced professionals who exercise latitude and independence in assignments. Responsibilities typically include: policy and strategy implementation for short-term results (1 year or less), problems faced are difficult to moderately complex, and influences others outside of own job area regarding policies, practices and procedures.