Transplant Quality and Performance Improvement Manager

• Full time - 40 hours per week
• Hybrid schedule available
• Must obtain CPHQ certification within 2 years of hire

• →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. This includes transplant financial coordinator team and quality/data teams.
• →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.

Excellent organizational and leadership skills Highly self-motivated professional with ability to work under pressure with tight deadlines Ability to achieve results with a high level of accuracy and attention to detail Demonstrated problem-solving and analytic skills Ability to prioritize and manage multiple projects, work independently and in a matrix-team or collaborative setting Outstanding knowledge of data analysis, reporting and budgeting Working knowledge of all MS Office applications including Word and PowerPoint

Standing, Walking, Sitting, Bending, Reaching with arms, Finger and hand dexterity, Talking, Hearing, Seeing, Lifting, carrying, pushing and or pulling:

20 lbs. maximum

Clean, comfortable, office environment

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.