Quality and Safety Manager

NFH•Louisville, KY

About The Position

At Network for Hope (NFH), the Quality and Safety Manager provides day-to-day leadership and oversight of the Quality Department, ensuring team efforts align with NFH's mission, core values, and strategic objectives. This role is responsible for maintaining the integrity and quality assurance of donor records, ensuring timely and accurate clinical data submission, and overseeing donor record review and release processes in compliance with regulatory and accreditation requirements. The Quality and Safety Manager leads external inspection and survey preparedness, oversees the organization's Business Continuity and Safety Program, and supports the implementation and coordination of the Patient Safety Program. This position also directs internal auditing activities, drives corrective and preventive actions, and promotes a culture of quality, safety, compliance, and continuous improvement across the organization.

Requirements

Bachelor's degree in Business Administration, Healthcare, Management, or similar field preferred.
Minimum of 3 years of compliance and/or safety experience required
healthcare and safety-related quality compliance or OPO environment preferred.
Proven experience managing safety reports, external inspections, audits, or surveys.
Minimum of three years of management or supervisory experience required.
Compliance related certification (e.g. ASQ, NAHQ, etc.) helpful but not required.

Nice To Haves

Compliance related certification (e.g. ASQ, NAHQ, etc.) helpful but not required.

Responsibilities

Provide daily operational oversight of the Quality teams, including planning and executing short and long-term operational goals in collaboration with the Patient Safety Officer.
Direct the goals, training, competencies, and evaluation of department positions responsible for compliance and compliance readiness activities.
Responsible for ensuring competence of staff through development and implementation of orientation programs, ongoing education and training, and focused learning activities.
Ensure adherence to organizational policies, procedures, and accreditation and regulatory standards.
Serve as subject matter expert for compliance to current organizational policies, procedures, and accreditation and regulatory standards.
Attend relevant local, regional, and national meetings as required or assigned to represent the interests of NFH and identify best practices to support organizational success.
Lead preparation efforts for external inspections and surveys by regulatory bodies, accreditation organizations, and other third parties.
Collaborate with NFH Leadership to ensure organizational compliance with current policies, procedures, and accreditation and regulatory standards.
Act as a primary point of contact during inspections and surveys, facilitating leadership and staff participation, coordinating requests for information, and managing immediate follow-up actions.
Provide routine consultation regarding organizational policies, procedures, and accreditation and regulatory standards to support understanding and adherence.
Coordinate and oversee leadership development, implementation, and effectiveness of required responses and improvement plans resulting from inspections or surveys.
Oversee and evaluate the effectiveness of quality assurance activities, including: Monitoring donor record quality assurance status, turnaround times, and closure, Ensuring accurate and timely submission of required clinical data elements, Ensuring timely identification, reporting, and verification of post-recovery culture and/or serology results, Providing routine quality assurance metrics and reporting.
Participate in recommendations for donor record and documentation improvements, including training and competency opportunities.
Coordinate the release of donor records in a manner that ensures the safety, security, and confidentiality of donor information in accordance with legal requirements and standard operating procedures.
Serve as the HIPAA Privacy Officer for the organization, including: Developing and maintaining procedures that protect the integrity of protected health information (PHI), Collaborating with Education and Development to ensure ongoing HIPAA and confidentiality training, Assisting leadership with reported breaches and coordinating corrective and preventive actions in accordance with regulatory and legal standards.
Oversee and coordinate the internal audit program to evaluate compliance with accreditation and regulatory standards and internal policies and procedures.
Develop and execute an annual audit schedule and ensure focused audits are conducted as needed.
Provide audit results to departments and oversee the development and implementation of improvement plans.
Ensure timely and effective resolution of identified issues.
Oversee the development, implementation, and ongoing maintenance of the organization's Emergency Preparedness/Business Continuity and Safety Program and serve as the emergency and business continuity Safety Officer.
Conduct regular risk assessments, training, and testing to ensure readiness for emergencies or disruptions in accordance with accreditation and regulatory standards.
Serve as a backup lead for patient safety events, including triage of safety calls, and support root cause analyses and investigations.
Collaborate with departments to ensure organizational and patient safety protocols are current and effectively communicated.
Monitor compliance with safety regulations and standards and coordinate improvement plans with leadership as necessary.