POSITION SUMMARY :
The Transplant Quality Coordinator (TQC) is r esponsible 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 The Joint Commission, UNOS, CMS and other regulatory agency standards. Plans, administers, and implements processes to support ongoing compliance and survey readiness. Models appropriate behavior as exemplified in SDNAMC's Mission, Vision and Values.
Participates in providing patient specific care standards as directed, and follows service excellence standards to ensure high levels of patient satisfaction. ESSENTIAL JOB RESONSIBILITIES : 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.
• Effectively communicates information from measurement and improvement activities to the appropriate constituents.
• Prioritizes improvement efforts based on alignment of clinical performance with patient safety and pro-active reduction of risk.
• Leads and/ or participates in cross-functional groups and/or committees to achieve quality, regulatory, and accreditation goals and objectives.
• Researches and incorporates best practice methodology to drive change and performance improvement initiatives.
• 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 constant 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
a timely response to regulatory agencies on corrective action plans, inquiries, and other requested information.
• Guides and coordinates policy/practice review to ensure alignment with regulatory and accrediting standards, best practices, and evidence-based practice.
• Measures internal compliance through data collection, tracking/trending, analysis, and monitoring. Presents findings and recommendations for performance improvement.
• Continually reviews and monitors Joint Commission, CMS and UNOS data and changes in interpretations; communicates new or modified regulatory standards as appropriate; makes recommendations to ensure compliance.
• Serves as the subject matter expert and resource for CMS and Joint Commission accreditation
standards and accreditation requirements specific to transplant programs.
• Coordinates data submission to various regulatory agencies as required; 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. Contacts
- Regular contact with clinical and operational leadership. Works in partnership with administrators, department leaders, and healthcare professionals .
- Contact with professionals from all disciplines across the region, state, and local level. Regular contact with vendors, professional colleagues, and regulatory and accrediting agency staff.
• Employee's conduct must reflect the Company's values and a commitment to the Code of Conduct ethics and compliance program.
• Employee reflects SDH Service Excellence standards in every interaction.
• Must be able to demonstrate understanding of national patient safety initiatives by strict compliance to all safety protocols and procedures as required by both HCA and St. David's North Austin Medical Center.
• Other duties as assigned. KNOWLEDGE, SKILLS AND ABILITIES :
- General understanding of the renal transplant process as well as alternative therapies for end-stage renal disease. A particular competence in the renal transplant evaluation process for both recipients and donors.
- Knowledge of transplantation, quality metrics, and medical ethics.
- Ability to comply with documentation standards in a timely fashion. Knowledge and abilities essential to the successful performance of the duties assigned to the position.
- Demonstrates resourcefulness, effective written and oral communication, diplomacy, and organizational and analytic skills.
- Self-directed, assertive and creative in problem solving, systems planning analytics knowledge.
- Ability to work effectively and collaboratively with interdisciplinary teams.
- Excellent computer and communication skills.
• Sound working knowledge of concepts, practices, and procedures related to quality improvement functions gained from at least 2 year's direct work experience managing quality improvement projects or quality programs preferred. Qualifications: EDUCATION AND EXPERIENCE :
LICENSES AND CERTIFICATES :
- Holds a BA or BS in Nursing, Health Administration or related business clinical healthcare field; Master's degree preferred in Healthcare administration.
- Three to five years' experience in medical field required; minimum of one year in quality background in a hospital or physician practice setting preferred;
- Transplant experience in a transplant setting or dialysis center preferred.
Required: Texas RN License or a Compact RN license from a NCLA Compact State
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom