Transplant Quality and Performance Improvement Manager

Advocate Health and Hospitals Corporation•Winston Salem, NC

8d•Hybrid

About The Position

The Medical Center is seeking a Transplant Quality and Performance Improvement Manager to lead quality, compliance, and performance improvement for the Solid Organ Transplant Program. This role oversees a multidisciplinary, data-driven QAPI program spanning all phases of transplant and donation, including pre-transplant, transplant, and post-transplant care for renal, pancreas, and cardiac transplant patients, as well as the LVAD program. The manager serves as the primary contact for regulatory and accreditation agencies and ensures compliance with applicable oversight bodies, including TJC, CMS, UNOS, OPTN, and others as needed. Responsibilities include identifying opportunities to improve quality, safety, efficiency, and patient experience; partnering with nursing leadership to support seamless service line delivery; and leading performance improvement initiatives in collaboration with Patient Safety and Risk Management. The role also provides project management, facilitation, and oversight for quality improvement and patient safety initiatives within Transplant Services. Additional responsibilities include employee performance evaluations, orientation, training, and working closely with medical staff to prepare for current and pending regulatory requirements. Change leadership is a key function of this position.

Requirements

Bachelor's Degree required in Nursing, or other relevant clinical discipline.
Previous experience in quality assurance/performance improvement role required.
Three years management experience in a similar role is required.
Proficient in the use of Word, Excel, PowerPoint, Visio and EPIC.
Active applicable state RN License
CPHQ certification

Nice To Haves

Master's Degree preferred in a health-related field, or MBA.
Must be willing to pursue higher education based on the needs of Transplant Services.
Must obtain CPHQ certification within 2 years of hire

Responsibilities

Responsible for the overall administration and coordination of the Transplant Quality Program, serves as the quality expert for Transplant Services.
Demonstrates leadership in the areas of Human Resources, Performance Improvement, Planning, Directing, Financial Management, Continuous quality improvement.
Prepares and maintains materials/documents used for surveys by OPTN, CMS/applicable state Department of Health for transplant centers and for Joint Commission certification.
Works directly with regulatory agencies to ensure compliance.
Generates action plans and ensures follow-up.
Leads managers and staff to assure continuous readiness for survey with policy and procedure review and revision, mock survey drills, and ongoing education.
Develops/revises/implements plans for response to unannounced surveys/visits.
Develops/revises oversight of all transplant related policies.
Coordinates scheduling of announced visits/surveys.
Prepares and submits reports UNOS reports including annual personnel report, changes in key personnel, and reports requested by the Membership and Professional Standards Committee.
Hospital Chapter leader for Joint Commission readiness team for transplant.
Responsible for maintaining the scorecards/dashboards and other reports used for Quality Assessment and Performance Improvement with the presentations for those meetings.
Organizes and facilitates multi-disciplinary teams to successfully implement performance improvement initiatives to achieve program quality improvement goals.
Annually coordinates a review of the PI indicators defined for each program and makes recommendations for revisions.
Oversees the ongoing medical record reviews, including reviews of documentation required for UNOS and CMS.
Collates and submits data related to these reviews to the leadership team and hospital departments as requested.
24-hour accountability for patient safety events and disease transmission events with Director of Transplant Services.
Utilizes Quality tools to determine causes of adverse events.
Develops Quality Improvement Plans.
Performs Root Cause Analysis, leads RCA teams.
Initiates and leads performance improvement teams.
Maintains competency in all organizational, departmental, and outside agency safety standards relevant to job performance for business unit and ensures business unit and staff compliance.
Maintains systems and processes to ensure continuous compliance with the CMS Conditions of Participation related to QAPI.
Directs and identifies needs for OPTN and CMS regulatory requirements, Joint commission specialty certification pay for performance initiatives, and works with payer directed centers of excellence programs.
Continuously analyzes systems and processes.
Develops and implements best practices and appropriate changes to improve outcomes in a timely manner.
Creates evaluation strategies to monitor performance and determines the need for improvements.
Initiates and sets goals for programs and functional area according to the strategic objectives of the organization.
Ensures program and functional area operations and activities adhere to any legal guidelines and internal policies.
Keeps senior management informed with detailed and accurate reports or presentations.
Develops appropriate communication and communication methods to facilitate the flow of information and maximizes effective communication throughout the program.
Communicates services with other departments and vendors as applicable.
Facilitates and leads monthly quality meetings for solid organ programs, leads transplant executive meeting in absence of the Director.
Develops, retains, recruits, and leads a talented management/clinical team committed to accomplishing the organizational/business unit goals, objectives, and corporate compliance.
Recommends, implements, and evaluates plans and systems to capture data and regulatory agency needs.
Supervises the work and manage performance of assigned staff such as responsibility for work assignment, performance reviews, and personnel change recommendations.
Participates in various medical center committees, work groups, and task forces as requested, including the hospital emergency preparedness committee to ensure compliance with regulatory requirements.

Benefits

Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program