Description

Responsibilities include development, implementation and maintenance of a comprehensive data driven transplant QAPI program designed to monitor and evaluate performance and compliance with CMS, OPTN/UNOS and other applicable regulatory agencies. Provides expertise to support a Quality Assurance and Performance Improvement (QAPI) program using LEAN/Six-Sigma methodology, as well as transplant expertise to support compliance with all regulations, guidelines, and standards with particular focus on CMS Conditions of Participation (COPs) for transplant centers, and UNOS/OPTN policies. Develops, monitors and implements standards, objectives, policies and procedures for the transplant program in conjunction with transplant program and Transplant Administration leadership in accordance with Medical Center standards. Activities of a transplant quality program include: maintenance and review of SOPs, performance improvement initiatives, training programs, competency assessment programs, corrective and preventive action plans, and tracking and management of adverse events. Performs audits of CMS and OPTN/UNOS-mandated multidisciplinary operational functions. Reviews and evaluates reports of adverse events, investigates as appropriate per the Department's Adverse Event Policy in conjunction with the Hospital Quality Department. Collects and analyzes quality metrics including but not limited to: patient survival, graft survival, patient and donor selection criteria, accuracy of waitlist in accordance with OPTN policy, accuracy of donor and recipient matching, patient and donor management, consent practices, patient satisfaction and patient rights. Works closely with the Solid Organ Transplant Nurse Managers for the programs to which he/she is assigned in preparing reports and monthly dashboards. Ensures, development of program's annual QAPI plan(s) and ensures adherence. Applies performance improvement tools and techniques consistent with Medical Center Performance Excellence guidelines.

Reports directly to the Manager, Transplant Quality and Compliance and Assistant Director and Director of Transplant Services and indirectly to the Medical and Surgical Directors of the Solid Organ Transplant Programs to which the QA Manager is assigned.

Salary Range: $86,900.00-$197,300.00/annually

Qualifications

Required:

• 3+ years of clinical healthcare work experience

• Bachelor's degree in Healthcare Administration, Public Health, Nursing, or Life Sciences

• Interpersonal skills to establish and maintain effective communication patterns and working relationships with transplant program leadership, clinical team members, and staff

• Excellent verbal and written communication skills

• Demonstrated ability to author professional correspondence and reports for both internal and external stakeholders

• Ability to communicate effectively with persons of various cultural and educational backgrounds

• Excellent analytical skills, proficiency in Microsoft Excel data management and analytical tools, knowledge and application of basic biostatistics principles

• Excellent ability to represent data and processes graphically with proficiency in Microsoft Excel, PowerPoint, Tableau and Visio

• Excellent organizational skills, proficiency in meeting deadlines, ability to work independently, but also be a team player, manage numerous concurrent tasks in a high-stress environment, deal with change and prioritize workload

• Flexibility to accommodate the full-time daily requirements of the programs as well as unplanned meetings and surveys as they occur

• Ability to analyze information to define the problem/objective; identify relevant factors, patterns or relationships; formulate objective conclusions and recognize alternatives and their implications

• Experience in project planning and monitoring with knowledge of process improvement and quality management

• Knowledge or familiarity with LEAN and/or Six Sigma process improvement tools

• Familiarity with Medical Center and University department functions and policies and procedures

• Knowledge and experience with data systems with the Medical Center

• General knowledge in the use of computerized clinical information systems

• Knowledge of transplantation and issues involving organ procurement

Preferred:

• Nursing background with clinical transplant experience

• Master's Degree in Health Administration, Public Health, Nursing, or Business Administration

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