Director of Quality Systems

Southwest Transplant Alliance•Dallas, TX

About The Position

The Director of Quality is responsible for leading the organization’s quality and performance improvement strategy, ensuring alignment with regulatory standards and organizational priorities. The role oversees quality functions including documentation review, regulatory reporting, and data monitoring, and uses data-driven insights to establish metrics and dashboards that support decision-making and continuous improvement. The Director identifies risks, leads investigations, implements corrective actions, and partners with leaders across the organization to promote accountability, consistency, quality, and safety. The position ensures preparedness for audits and accreditation activities and serves as the primary liaison for regulatory agencies, accreditation organizations, external auditors, and other stakeholders. It also provides financial stewardship by aligning quality initiatives with resource optimization and organizational sustainability. The role requires a bachelor’s degree in health care administration, public health, nursing, or business, with a master’s degree preferred. A combination of alternative education and experience may be considered in lieu of the formal education requirements. At least five years of experience managing Quality Systems, including reporting and analytics, is required. Healthcare, OPO, transplant center, or related regulated-industry experience is preferred. A current driver’s license and an acceptable driving record as defined by STA policy are required. This position is classified as OSHA Bloodborne Pathogens Exposure Category III. Employees are not routinely expected to perform tasks involving contact with blood, bodily fluids, or other potentially infectious materials; exposure risk is minimal. Employees must follow organizational safety policies and promptly report potential exposure incidents. The role requires compliance with HIPAA and confidentiality standards for patient, donor, employee, and organizational information.

Requirements

Bachelor’s degree in health care administration, public health, nursing, or business is required; a combination of alternative education and experience may be considered in lieu of the formal education requirements.
At least 5 years of experience managing Quality Systems, including reporting and analytics.
Current driver’s license maintained with an acceptable driving record as defined by STA policy.
Comply with organizational safety policies and promptly report potential exposure incidents.
Comply with HIPAA and confidentiality standards and safeguard confidential patient, donor, employee, and organizational information.

Nice To Haves

Master’s degree.
Experience in healthcare, an OPO, a transplant center, or a related regulated industry.

Responsibilities

Provide strategic leadership for the organization’s Quality Assessment and Performance Improvement (QAPI) program, aligning it with organizational goals, regulatory requirements, and long-term performance objectives.
Lead and oversee organ and tissue chart reviews to ensure completeness, accuracy, regulatory compliance, and adherence to documentation standards.
Conduct and supervise CMS-required death record reviews to identify missed referrals, trends, documentation gaps, and systemic improvement opportunities.
Direct OPTN reporting and data submissions, ensuring timely, accurate, and compliant reporting aligned with OPTN.UNOS requirements and internal quality standards.
Establish enterprise-wide quality monitoring systems to identify risk, process variation, and performance trends.
Lead structured policy and procedure review cycles to align them with regulatory standards, best practices, and organizational priorities.
Develop and track quality metrics and dashboards related to chart reviews, death record reviews, reporting accuracy, and compliance outcomes; communicate findings to executive leadership and the Board as appropriate.
Translate data insights into strategic operational improvements and continuous improvement initiatives.
Manage the variance management system, including severity assignment, investigation oversight, root cause analysis, and development and monitoring of corrective and preventive action (CAPA) plans.
Monitor data integrity across systems, identifying discrepancies, systemic risks, and opportunities for corrective action.
Oversee document control to ensure policies, procedures, and forms are current, standardized, and compliant.
Support readiness for regulatory surveys, audits, and accreditation activities through proactive quality monitoring, mock surveys, and documentation oversight.
Identify emerging regulatory, operational, and compliance risks and implement mitigation strategies.
Ensure adherence to CMS, OPTN, and applicable federal and state regulatory standards.
Evaluate the financial impact of quality initiatives, regulatory findings, documentation errors, and process inefficiencies; develop cost-effective improvement strategies.
Align quality improvement priorities with organizational financial goals to reduce risk exposure, prevent financial penalties, and protect reimbursement.
Develop and manage the Quality department budget, allocating resources, technology investments, and staffing to support compliance and performance goals.
Use data analytics and reporting systems to improve operational efficiency and reduce waste or duplication.
Assess return on investment for quality initiatives, audit processes, and system enhancements.
Lead and oversee quality team members, setting clear expectations and supporting accountability, professional development, and succession planning.
Foster transparency, learning, and psychological safety, encouraging reporting of variances and near misses.
Provide quality-focused consultation and education to staff and leadership to strengthen quality culture and consistent performance improvement.
Facilitate cross-department collaboration and establish feedback loops between Quality and operational teams to support shared ownership of performance outcomes.
Model data-driven decision-making and promote accountability throughout the organization.
Serve as the primary quality liaison for regulatory bodies, accreditation organizations, and external auditors.
Interpret evolving regulatory guidance and translate requirements into operational standards.
Present quality performance, risk trends, and corrective action plans to executive leadership and governance bodies.
Represent the organization in external quality collaboratives, benchmarking initiatives, and industry forums.
Perform other job-related duties consistent with the purpose of the role.