Description
The position of the Transplant Quality Specialist will work with the designated Organ Transplant Programs to provide oversight and will assist in maintaining compliance with the requirements of the external agencies specifically related to transplant regulations as set by the Organ Procurement Transplant Network (OPTN) / United Network for Organ Sharing (UNOS) and CMS Regulations, Joint Commission, Intermacs, and the ESRD Network. The Transplant Quality Specialist will be responsible for spearheading and providing oversight to the development, coordination, implementation, and evaluation of quality improvement initiatives; taking lead on investigating reported internal and external events, transplant adverse events, and working with leadership and operations on corrective and preventative action plans; participates and may take lead in RCAs; participating in on-site surveys with OPTN/UNOS and CMS; responsible for patient chart audits, providing data feedback, and reporting transplant data on the MOTC dashboard; and responsible for providing statistical data reports, data analysis, and provide insight on opportunities identified through the data analysis. The Transplant Quality Specialist will be responsible for writing and revising policy in collaboration with the physician and transplant leaders. The Transplant Quality Specialist will be expected to work collaboratively with the physician and operational leadership. The position requires strong organizational and analytical skills, time management, ability to work in fast paced – team environment, and is able to multi-task and excel under pressure.
The position of the Transplant Quality Specialist will work with the designated Organ Transplant Programs to provide oversight and will assist in maintaining compliance with the requirements of the external agencies specifically related to transplant regulations as set by the Organ Procurement Transplant Network (OPTN) / United Network for Organ Sharing (UNOS) and CMS Regulations, Joint Commission, Intermacs, and the ESRD Network. The Transplant Quality Specialist will be responsible for spearheading and providing oversight to the development, coordination, implementation, and evaluation of quality improvement initiatives; taking lead on investigating reported internal and external events, transplant adverse events, and working with leadership and operations on corrective and preventative action plans; participates and may take lead in RCAs; participating in on-site surveys with OPTN/UNOS and CMS; responsible for patient chart audits, providing data feedback, and reporting transplant data on the MOTC dashboard; and responsible for providing statistical data reports, data analysis, and provide insight on opportunities identified through the data analysis. The Transplant Quality Specialist will be responsible for writing and revising policy in collaboration with the physician and transplant leaders. The Transplant Quality Specialist will be expected to work collaboratively with the physician and operational leadership. The position requires strong organizational and analytical skills, time management, ability to work in fast paced – team environment, and is able to multi-task and excel under pressure.
Essential Duties:
- Compliance: Compiles survey findings and develops related plans of correction. Maintains policy and procedures to support alignment with regulatory requirements and works with program leadership to support alignment with program practice. Prepares and maintains materials/documents used for surveys by CMS, UNOS, and Joint Commission. Participates in the preparation of corrective action plans in response to regulatory surveys and to internal and external reported events Coordinates scheduling of announced visits/surveys and participates in the survey process in collaboration with Transplant Institute leaders Assists and contributes to the Transplant Institute leaders and staff to assure continuous survey readiness with policy and procedure development, review and revision, mock survey drills, and ongoing education Monitors and tracks compliance with UNOS requirements for data submission. Works with management if there is not full compliance. Completing audits as needed to assess compliance. Primary interface with regulatory agencies (CMS, Joint Commission, Intermacs – as applicable) Maintains current working knowledge of requirements related to CMS conditions of Participation, Joint Commission Disease Specific Certification for VAD,OPTN/UNOS Policies and Bylaw, PHS Increased Risk Guidelines, and any other transplant standards, guidelines, and recommendations.
- Reports and Policy Preparation and Administration: Coordinates preparation of UNOS reports including annual personnel report, changes in key personnel and reports requested by the Membership and Professional Standards Committee. Oversee the maintenance of the OPTN data entry system for transplant centers (TIEDI) Oversee the accurate reporting of all graft losses and patient deaths via TIEDI in a timely manner. Creation of departmental policy in collaboration with administration and Transplant Institute leadership, as well as policy revisions. Responsible for keeping up with UNOS/OPTN policy/bylaw and CMS regulations and ensuring Transplant Institute policy is incompliance and aligned with the regulations. Revises documentation forms and consent forms as indicated. Revises documentation forms and consent forms as indicated. Coordinates development and preparation of quality reports and Quality Plans for all Transplant Programs and the VAD program, and maintains the MOTC Dashboard for MOTC quarterly meetings. Coordinates with the Transplant Institute Leadership presentation of quality data/dashboards to the MOTC. Assists in the completion of UNOS/insurer's RFI on an annual basis in collaboration with the program managers and program medical directors. Oversees the ongoing medical record reviews, including reviews of documentation required for CMS and UNOS. Organ Transplant Database super user
- Performance Improvement: Participates in planning and implementing systematic processes to improve the quality and safety of patient care, and operational effectiveness of the program. Reports outcomes, opportunities for improvement, and best practices to the designated transplant program(s), Transplant Institute leadership and / or hospital committees as requested. Report, monitor and investigate risk/safety events that occur within the Transplant Institute. Develop and recommend corrective action plans, to improve patient quality and safety when undesirable patterns are identified. Active participant in root cause analysis of sentinel events that occur within the Transplant Program. Communicate events and findings with Transplant Institute leadership and appropriate staff. Supports and coordinates Morbidity and Mortality Conferences in collaboration with the Physician Leadership. Develop and implement process to analyze and predict patient and graft survival as will be reported via SRTR cohorts. Maintain collaborative, working relationship across the healthcare continuum and disciplines involved with transplant patients including the OR, VIO, and various patient units within Keck Hospital of USC. Coordinate organ offer review meetings on a monthly basis and monitor organ declines in collaboration with the Transplant Call Team and Transplant Physician Leadership Annually revises the Performance Improvement Indicators defined for each program and makes recommendations for revisions for the upcoming year. Work with Transplant Institute leadership and team to develop, review, revise and monitor policies, protocols, and forms to ensure best practice to standardize clinical care, reduce practice variation, and to ensure effective workflows
- Participates, contributes, and coordinates the QA Transplant Programs regularly scheduled meetings.
- Performs other duties as assigned.
Required Qualifications:
- Req Bachelor's degree in a related field.
- Req 2 years Transplant environment and/ or transplant quality assessment and performance improvement experience.
- Req Well versed in CMS regulations and OPTN/UNOS policies and bylaws.
- Req Demonstrates strong organizational skills and ability to work independently as well as strong project management skills Effective personal and professional written and verbal communication skills.
- Req Work effectively with physicians and team as well as with multidisciplinary staff across clinical and non-clinical areas. Proficient in Word, Excel, PowerPoint, and Internet applications.
- Req Demonstrates customer service values.
- Req Strong knowledge of healthcare trends in transplantation and quality improvement concepts.
- Req Strong analytical and problem solving skills.
- Req Strong critical thinking and decision making skills.
Preferred Qualifications:
- Pref Master's degree in a related field.
Required Licenses/Certifications:
Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
The annual base salary range for this position is $68,640.00 - $112,370.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
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