Manager, Transplant QAPI

WVU Medicine - Morgantown, WV3.3

Full-timeEstimated: $67,000 - $96,000 a year
EducationSkills
JOB TITLE & CODE:
Manager, Transplant QAPI (86510)

DEPARTMENT:
Transplant

REPORTS TO:
Director

FLSA STATUS:
Exempt

POSITION SUMMARY: Will lead and manage the Quality Assurance Process Improvement (QAPI) programs for the solid organ transplant teams in compliance with regulatory agency guidelines. Lead cross-functional quality/process improvement. Conduct complex transplant data analysis, present data and analysis findings to organ teams for Root Cause Analysis discussion, identification, and implementation of evidenced based-best practices for quality improvement and research initiatives. Maintain dashboards, present monthly organ specific dashboards to organ teams and directors, provide data interpretation, and answer questions to guide teams in identification of issues.

MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1.

Bachelor’s degree in Nursing

2.

Current unencumbered licensure with the WV Board of Registered Professional Nurses, or appropriate state board where services will be provided, as a registered professional nurse OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

3.

Obtain certification in Basic Life Support within 30 days of hire date.

EXPERIENCE:
1.

Five (5) years of experience in quality team facilitation, project management, process improvement or quality data analysis.

PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1.

Master’s degree

EXPERIENCE:
1.

Joint Commission, Transplant CMS and UNOS experience

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1.

Oversees an effective transplant quality assurance and performance improvement (QAPI) program that is multi-disciplinary in nature, data driven and covers all phases of transplant and donation in a continuous cycle of review and improvement while addressing patient safety, clinical care, quality of life, and those services provided under contract or arrangement. Ensures that the program utilizes defined methods for conducting analyses, developing and implementing corrective actions, monitoring improvements, and assessing the effectiveness and sustainability of actions taken.

2.

Oversees management of transplant patient safety events and patient concerns including internal and external reporting (per transplant regulatory requirements) in conjunction with organizational patient safety and regulatory leadership.

3.

Maintains currency with transplant regulations for all agencies and ensure WVU leadership, transplant program leadership and staff are kept apprised of changes in regulation and that practices are aligned with regulatory requirements.

4.

Responsible for the management of transplant related data and data reporting both internally to WVUH and externally to regulatory agencies. Oversees UNOS data administration and reporting.

5.

Collaborate with leadership of collateral departments through the organizational matrix to support transplant patient QAPI, Safety and regulatory compliance.

6.

Serves as a liaison with the transplant team on UNOS/CMS/ESRD Network 5 requirements and monitoring.

7.

Manages and strategies for the unannounced UNOS and CMS on-sight or desk audits.

8.

Policy/Procedure/Guideline management and review (document control processes): schedule review of existing policy, participate in review of every policy for content clarity, adherence to regulatory/accreditation Standards, conflicts with other, encourage/facilitate collaboration between services when responsibilities are shared and impact is broad.

9.

Provides leadership, education and mentoring of all personnel in quality assessment, data and financial management, reporting and quality improvement plan and initiatives.

10.

Audits/Monitors Projects: selecting, developing, performing and/or facilitating, analyzing, reporting.

11.

Analyzes and recommends/implements changes in operating systems and related policies and procedures to ensure program quality.

12.

Assist Director of Transplant Operations and Compliance lead the multidisciplinary teams to focus on clinical outcomes as well as improving the overall operations of the department.

13.

Analyze SRTR data input, verify data, generate reports including those that meet the reporting requirements for UNOS and associated transplant regulatory

14.

Coordinates for UNOS annual personnel report, change in key personnel, and reports requested by the Membership and Professional Standards Committee.

15.

Alerts leadership of any non-compliance with the requirements.

16.

Maintain and identify areas for changes in budget (supplies, hours, etc.)

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.

Requires full range of body motion, manual finger dexterity, hand and eye coordination.

2.

Requires working under stressful conditions

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.

Desk work (phone calls, computer, completing paperwork, etc)

SKILLS AND ABILITIES:
1.

Strong interpersonal and communication skills.

2.

Proficient computer/keyboard skills

3.

Ability to work independently, handle multiples tasks, set appropriate priorities and accomplish assignments in a thorough and timely manner.

4.

Demonstrates critical thinking skills

5.

Ability to work independently

Date Reviewed/Revised: September 2018