Director of Transplant Quality and Medical Staff
3 weeks ago
The Director of Transplant Quality and Compliance will lead quality assurance, regulatory compliance, and process improvement initiatives within our transplant center.
This role oversees the staff education program and the transplant Information Systems (IS) team, ensuring comprehensive management of all quality, compliance, and operational aspects of the transplant program.
Key responsibilities include:
- Developing and implementing a comprehensive quality management system for the transplant program
- Leading continuous quality improvement initiatives across all aspects of transplant care
- Analyzing quality metrics and outcome data to identify areas for improvement
- Ensuring compliance with all relevant federal, state, and local regulations, including UNOS/OPTN policies
- Overseeing the preparation and maintenance of all required documentation for regulatory inspections and audits
- Managing relationships with regulatory bodies and accreditation organizations
- Identifying and implementing process improvements to enhance operational efficiency
- Developing and monitoring key performance indicators (KPIs) for operational efficiency
- Overseeing the development and implementation of comprehensive education programs for transplant staff
- Ensuring all staff members receive up-to-date training on regulatory requirements, clinical protocols, and best practices
- Ensuring compliance with continuing education requirements for all transplant staff
- Overseeing the implementation, maintenance, and optimization of transplant information systems
- Ensuring that IS solutions meet regulatory requirements and support efficient clinical workflows
- Developing and maintaining data management systems for accurate reporting and analysis
- Staying informed about emerging technologies in transplant care and evaluating their potential implementation
- Managing quality and compliance staff, staff educator, and transplant IS team within the transplant program
- Participating in strategic planning for the transplant program
- Representing the transplant center in regional and national quality forums
- Fostering a culture of continuous learning and improvement across all teams under supervision
- Providing leadership and mentorship to quality and compliance team members
Requirements include a Master's degree in a relevant field of study and seven or more years of relevant experience; demonstrated experience in quality improvement, regulatory compliance, operational efficiency, staff education, and information systems management in a transplant setting.
Demonstrated knowledge of organ transplant CMS Conditions of Participation and UNOS/OPTN policies, Title 22, and hospital Joint Commission requirements.
Proficiency in quality improvement methodologies (e.g., Lean, Six Sigma). Strong analytical skills with experience in data analysis and performance monitoring. Excellent project management and change management skills. Proficiency in electronic medical records systems and data reporting tools. Understanding of adult learning principles and educational program development. Master's degree in Nursing. Certified in healthcare quality (CPHQ), Lean Six Sigma Black Belt (LSSBB) or similar certification. Experience in Epic/ Phoenix transplant EMR module.
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