Summary

Responsible for managing the process for continuous regulatory and accreditation compliance, quality, and patient safety for the Transplant Program and associated clinical areas. Serves as advisor and subject matter expert in DNV, CMS and other regulatory agency standards. Plans, administers, and implements processes to support ongoing compliance and survey readiness. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

Knowledge/Skills/Abilities

• Sound working knowledge of concepts, practices, and procedures related to quality improvement functions.
• Demonstrated knowledge and expertise in the application of advanced quality tools and methodologies.
• Strong facilitation skills with proven ability to plan, implement, coach and assist others in performance improvement measures.
• Strong technical ability in basic business software such as Excel, PowerPoint, Word, and statistical analysis software such as Minitab. Technical skill in database software such as Access is desired.
• Experience with DNV, state licensure and CMS Conditions of Participation survey process and regulatory compliance.
• Demonstrated capability in facilitating a collaborative approach to compliance with regulatory standards.
• Ability to consult and negotiate in situations that are controversial and/or sensitive that result in mutual decisions. Ability to exercise discretion in what and how to communicate.
• Ability to read and interpret complex statutes and regulations and apply knowledge to manage compliance risk exposure.
• Demonstrated ability to manage by influence in a consultative role that does not have direct authority.
• Strong professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the organization.
• Ability to lead and motivate individuals and groups toward the accomplishment of organizational goals.
• Possesses good analytical and problem solving skills. Demonstrates a high level of organizational skills to establish and manage priorities and maintain follow-up.

Key Job Responsibilities

Quality

• Collaborates with medical staff and operational leadership to facilitate evidence-based quality and patient safety initiatives; engages associates at all levels in continuous pursuit of improvement opportunities.
• Manages, coordinates, and provides oversight of key functions and processes for the systematic, coordinated, and continuous improvement of patient care delivery.
• Ensures quality and performance improvement initiatives are aligned with regulatory standards and healthcare best practices.
• Establishes and maintains efficient and reliable mechanisms for monitoring, analysis, and reporting of quality outcomes and performance improvement initiatives. Ensures the integration of aggregate data into performance improvement planning and problem resolution.
• Coordinates and facilitates the use of statistical process tools and process improvement methodologies for continuous improvement in patient care and outcomes.
• Evaluates the relationship of quality and performance improvement initiatives with patient outcomes to determine if desired results have been achieved or sustained. Compares performance data and outcomes with authoritative external sources and benchmarks.
• Prioritizes improvement efforts based on alignment of clinical performance with patient safety and pro-active reduction of risk.
• Leads or participates in cross-functional groups and/or committees to achieve quality, regulatory, and accreditation goals and objectives.
• Coordinates with hospital clinical risk management to identify adverse events, communicate the events to the transplant program leadership and staff, and support the root cause analysis and improvement/remediation related to these events.

Regulatory Readiness

• Responsible for the coordination of accreditation and regulatory standards for the transplant program. Plans and implements programs to assess state of readiness for surveys, focusing upon continual preparation
• Establishes and implements processes to support ongoing compliance and survey readiness. Collaborates with leadership and team members to meet accreditation and compliance goals and objectives.

• Coordinates survey visits/activities and post-survey follow-up activities. Prepares and coordinates responses to regulatory agencies on corrective action plans, inquiries, and other requested information.
• Measures internal compliance through data collection, tracking/trending, analysis, and monitoring. Presents findings and recommendations for improvement.
• Serves as the subject matter expert and resource for DNV accreditation standards and accreditation requirements specific to transplant programs.

Management & Consultative

• Develops, delivers, and coordinates training, education, and communications for team members to comply with regulatory and accreditation standards.
• Participates as a team leader or member in system or facility performance improvement/regulatory readiness or quality teams. Builds mutual trust and encourages respect and cooperation among team members to support movement from current state of practice to desired state of practice, address and mutually resolve issues.
• Supervises support staff as assigned. Monitors Associate performance and clarifies work expectations, and assists with goal setting; promotes cooperation among individuals and groups. Develops and implements processes through orientation, training and education to ensure that the competence of staff members is assessed, maintained, improved and demonstrated throughout their employment.

Physical Requirements