Kidney/Pancreas QA Manager

The incumbent reports directly to the Manager, Transplant Quality and Compliance and Assistant Director, and Director of Transplant Services and indirectly to the Medical and Surgical Directors of the Solid Organ Transplant Programs to which the QA Manager is assigned.

Responsibilities include:

• Development, implementation and maintenance of a comprehensive data driven transplant QAPI program designed to monitor and evaluate performance and compliance with CMS, OPTN/UNOS and other applicable regulatory agencies.

• Provides expertise to support a Quality Assurance and Performance Improvement (QAPI) program using LEAN/Six-Sigma methodology, as well as transplant expertise to support compliance with all regulations, guidelines, and standards with particular focus on CMS Conditions of Participation (COPs) for transplant centers, and UNOS/OPTN policies.

• Develops, monitors and implements standards, objectives, policies and procedures for the transplant program in conjunction with transplant program and Transplant Administration leadership in accordance with Medical Center standards.

• Activities of a transplant quality program include maintenance and review of SOPs, performance improvement initiatives, training programs, competency assessment programs, corrective and preventive action plans, and tracking and management of adverse events. Performs audits of CMS and OPTN/UNOS-mandated multidisciplinary operational functions. 

• Reviews and evaluates reports of adverse events, investigates as appropriate per the Department’s Adverse Event Policy in conjunction with the Hospital Quality Department.

• Collects and analyzes quality metrics including but not limited to: patient survival, graft survival, patient and donor selection criteria, accuracy of waitlist in accordance with OPTN policy, accuracy of donor and recipient matching, patient and donor management, consent practices, patient satisfaction and patient rights.

• Works closely with the Solid Organ Transplant Nurse Managers for the programs to which he/she is assigned in preparing reports and monthly dashboards.

• Ensures development of program’s annual QAPI plan and ensures adherence.

• Applies performance improvement tools and techniques consistent with Medical Center Performance Excellence guidelines