DESCRIPTION

Under general direction from the Lifesharing Executive Director, the Director of Quality and Performance Improvement is responsible for the creation, implementation and oversight of the Quality Plan that complies with all pertinent regulatory agencies and governing bodies for the Organ Procurement Organization. This includes management an execution of Quality Control and Quality Assurance policies and staff. Ensures the review, creation, updates and maintenance of all organizational standard operating policies and procedures, ensuring that all policies and procedures are in compliance with local, state, federal and industry standards.

The Director ensures there is adequately trained staff to accomplish Quality objectives and maintain compliance with applicable federal and state regulations as well as industry standards. Ensures organization achieves and maintain regulatory standards and industry accreditation and ensures completion and submission of data required by those specific agencies; CMS, UNOS, AOPO and OPTN.

The Director manages the internal and external audit program for the organization. Independently conducts and oversees all internal and external audits needed to maintain regulatory and voluntary accreditation. Manages and runs the corrective and preventative action program (CAPA) for the organization, includes detecting variances, reporting findings, and providing education for improvement. Ensures thorough investigations and root cause analysis are conducted appropriately and all documentations accurate and complete.

Incumbent maintains the document control system for all policies, procedures and controlled documents, tracking training and variances. Responsible for monitoring, coordinating, and promoting the Performance Improvement process as it relates to internal standards, industry standards, organizational goals, organ clinical services, required employee training and safety and works to yield results that raise performance, lower costs, and improve quality standards. Generates tracks and independently interprets reported data for accuracy and develops trend analysis of organization performance. Works with leadership team to develop performance improvement plans based on data. Reports to management team and staff on a scheduled basis.

Key Responsibilities:
- Supervises and coordinates the department operations, resolves system issues, advises on work methods, functions as a subject matter resource, and assists with escalated issues.
- Interprets and analyzes internal and external changes in policies and procedures related to QI practices. Keeps staff informed of changes and updates in processes, technology, regulations, and quality standards.
- Collaborates with management on operational and performance issues and the development of new programs to better integrate QI into clinical departments. Oversees the implementation of new clinical QI plans and initiatives.
- Oversees data collection and reporting activities; ensures the efficient and timely flow of data to internal and external databases. Monitors the measurement and quality metrics of the department and determines methods to improve the data collection process.
- Evaluates subordinate staff and participates in decision-making on hiring, salary actions, terminations, performance ratings, and other human resources matters.
- Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
- Oversees staff responsible for partnering with clinical departments to identify and implement strategies to improve quality of patient care. Ensures clinicians receive support on quality structuring, quality data analysis, data abstraction tools and techniques.
- Participates in or leads teams and partnerships with clinical and technical staff to monitor and develop practice specific indicators and performance measurement techniques.
- Ensures that effective systems are in place to support the collection, measurement, and analysis of accurate data and the preparation of consistent, reliable reports.
- Other duties as assigned.

MINIMUM QUALIFICATIONS

• Bachelor's Degree in healthcare or related profession; or a combination of comparable clinical education and experience.

• Five (5+) or more years of relevant experience in quality and performance improvement.

• Experience and proven ability to effectively supervise a team and to manage the complex workflow and multiple priorities involved with quality improvement.

PREFERRED QUALIFICATIONS<