Description
Assists in implementation of quality improvement and patient safety initiatives for transplant services. Responsible for policy implementation and compliance of all donation and transplant related regulatory agencies including CMS UNOS and The Joint Commission.
- Develops and maintains the quality assessment/performance improvement (QAPI) program for transplant services in collaboration with the manager of Transplant Quality.
- Ensures compliance with current legislative/regulatory requirements.
- Ensures the Transplant Center?s readiness for audit at all times.
- Provides educational support to all departments/units in the areas of transplantation quality improvement patient safety accreditation standards and other regulatory standards.
- Maintains knowledge of and expertise in requirements related to Medicare Conditions of ParticipationUNOS policies and bylaws as well as The Joint Commission standards for the hospital program.
- Assists with revisions and maintains change control for all Transplant Center forms policies protocols and guidelines.
- Assists with audits as needed to assess compliance.
- Collaborates with the Data Technicians to ensure the collection aggregation and analysis of data for the program including required UNOS reports quality indicators compliance measures and other ad–hoc reports are done successfully.
- Works to improve functionality of transplant data and related databases.
- Assists the Manager of Transplant Quality transplant leadership and transplant staff to identify opportunities and develop action plans to drive improvement of patient care treatment and services.
- Provides expertise and supports the activities of process improvement sub–committees.
- Develops action plans and coordinates improvement projects to support best practices regulatory compliance and strategic initiatives.
- Communicates transplant related quality outcomes safety issues and regulatory issues to appropriate staff other involved disciplines/clinical areas involved in the care of transplant patients Office of Clinical Quality and Safety and appropriate regulatory agencies.
- Works in conjunction with quality/risk management in analyzing and responding to adverse events and/or potential disease transmissions that occur in the transplant patient population.
- Facilitates mortality reviews as needed.
- Oversees preparation and reporting activities related to regulatory requirements.
- Coordinates scheduling and activities of announced surveys/reviews and activities for unannounced surveys/reviews.
- Ensures transplant service maintains continuous compliance with all requirements.
- Facilitates patient event reviews.
In addition to the above job responsibilities, other duties may be assigned.
MINIMUM REQUIREMENTS
Education: Graduate of an accredited program of clinical specialty; i.e. RN Radiography Pharmacy Social Work or Therapy Services. Bachelor's Degree is required. RN preferred.
Experience: 3 years of clinical quality or regulatory experience required; clinical quality or regulatory experience in transplant services preferred.
Licensure: Must hold current License of Specialty area. RN license preferred.
PHYSICAL DEMANDS
Job requirements: Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20lbs.
The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician?s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.
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