Transplant Quality Coordinator THOR

Transplant Quality Coordinator

At Houston Methodist, the Transplant Quality Coordinator position is a registered nurse responsible for working collaboratively with medical/surgical staff, department leadership, hospital leadership, and hospital quality and accreditation team members to ensure regulatory compliance with CMS Conditions of Participation for Transplant Centers, United Network of Organ Sharing (UNOS), Texas Department of Health Services (TDHS), and hospital accreditation agencies. This position assists program leadership with continuous assessment and improvement of the quality of care delivered to the pre, post, and LVAD patient populations through monitoring of clinical outcomes of Transplant/VAD services, including organizing, collecting, validating, compiling, analyzing, and reporting results of these services/programs. The Transplant Quality Coordinator position oversees the development of policies and procedures and creates quality improvement processes associated with Transplantation/VAD while facilitating adherence to regulatory agencies. This position supports and promotes the organization-wide quality program.

Job Description

• Communicates in an active, positive, and effective manner to all transplant team members, physicians, and staff who are part of the interprofessional transplant program in order to facilitate quality activities and regulatory compliance goal attainment.

• Collaborates with management in monitoring and evaluating quality of care and patient outcomes for the transplant/VAD patient population based on standards of care as well as the findings of nursing research, hospital policies/procedures, and applicable patient care protocols.

• Serves as a clinical resource to staff members. Fosters a teamwork approach in all interactions with peers and team members and provides quality/compliance education in order to promote individual staff member accountability and responsibility. Proactive and effective in developing and maintaining collaborative relationships with physicians, management, and staff. Uses peer-to-peer accountability towards improvement of department score for turnover/retention/employee engagement.

• Promotes department/service line understanding of the Transplant CMPI program. Supports and assists management and physicians in coordinating and facilitating CPI committee meetings and maintaining the MCPI documentation for the transplant center.

• Maintains ongoing clinical data in support of assessment and improvement of quality of care. Prepares internal or external clinical data requests.

• Facilitates collection of all clinical documents and data necessary in preparation for onsite review or regulatory response submission to any transplant regulatory agency. Participates as a liaison during certification/review site visits.

• Collaborates with Transplant Services leadership and staff to ensure ongoing compliance with the requirements, regulations, and laws of local, state, and federal regulatory agencies for transplant, including UNOS and CMS. Updates department policies in collaboration with the team to reflect current laws, regulations, and requirements of the regulating bodies and works to ensure practice is consistent with regulatory requirements.

• Facilitates an interprofessional approach to identify opportunities for performance improvement, facilitates change, assists with follow-up and evaluation of performance improvement activities as evidenced by defined metrics and achievement of defined outcomes. Facilitates the development of action plans in collaboration with staff and management. Makes recommendations for change in practice to improve patient outcomes.

• In collaboration with administrative and physician leaders, develops and implements reporting processes regarding clinical quality across all organ transplant/VAD programs.

• Analyzes and confirms data reported by the Scientific Registry of Transplant Recipients (SRTR) including overseeing UNOS data entry audits in preparation for SRTR report publication.

• Participates in the development, implementation, evaluation, and revision of order sets, policies, and other documentation. Monitors outcomes of current policy, process/system changes and reports variances to appropriate management and staff.

• Implements quality improvement projects involving data collection, validation, analysis, and reporting. Offers innovative solutions through participation in performance improvement projects. Contributes to department initiatives for quality and process improvement. Identifies opportunities for improvement based on data analysis. Contributes to meeting department and organ program targets for quality and safety.

• Maintains and submits accurate data for hospital-based statistics and regulatory agencies such as UNOS/UNET, CMS, and Medicaid in order to ensure proper department financial management.

• Contributes to meeting department and organ program financial measures.

• Participates in transplant-specific continuous learning and growth. Applies evidence-based practice to daily work, such as reviewing the professional literature and attending professional meetings and sharing with colleagues. Stays abreast of and shares knowledge of current trends in transplant nursing and CMS and UNOS regulations. Identifies own learning needs and actively seeks educational opportunities, both formal and informal, to meet those needs. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Requirements

• Bachelor's degree or higher from an accredited School of Nursing or Graduate of accredited medical school degree.

• Five years of nursing experience, which includes two years Transplant or Quality experience or five years' experience as a physician.

• Experience with managing regulatory reporting and audit processes.

• Project management experience preferred.

Licenses and Certifications - Required

• RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR

• RN-Temp - Registered Nurse - Temporary State Licensure within 60 days AND

• Magnet - ANCC Recognized Certification (ANCC) For RNs, in Quality Transplant within 18 months OR

• MD - Physician - State Licensure AND

• ABMS-CCM - ABMS-Critical Care Medicine (ABIM) For Physicians OR

• ABMS-ABIM - American Board of Internal Medicine-General (ABIM) For Physicians.

Knowledge, Skills, and Abilities

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations.

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.

• Ability to effectively communicate with patients, physicians, family members, and co-workers in a manner consistent with a customer service focus and application of positive language principles.

• Demonstrates strong knowledge of organ failure clinical processes.

• Demonstrates knowledge of hospital or specialty services regulatory reporting, accreditation, and audit processes.

• Demonstrates knowledge and application of process improvement tools and techniques (statistical process control tools and team tools).

• Ability to define problems, collect data, establish facts, draw valid conclusions, and evidence performance improvement via measurable results.

• Ability to enter and abstract data, as well as the ability to utilize data to facilitate improvement and change in processes. Able to navigate transplant applications and data systems (UNET, DonorNet, Tiedi).

• Working knowledge of Microsoft products.

Supplemental Requirements

Work Attire

• Uniform: No

• Scrubs: No

• Business professional: Yes

• Other (department approved): No

On-call

Note that employees may be required to be on-call during emergencies (i.e., Disaster, Severe Weather Events, etc.) regardless of selection below.

• On Call: Yes

Travel

Travel specifications may vary by department.

• May require travel within the Houston Metropolitan area: No

• May require travel outside Houston Metropolitan area: No

Community Overview

Houston Methodist Hospital is recognized by U.S. News & World Report as the No. 1 hospital in Texas and one of America's "Best Hospitals." As a full-service acute-care hospital located in the Texas Medical Center and the flagship hospital of Houston Methodist, it has evolved into one of the nation's largest nonprofit teaching hospitals and a leader in innovative medical research with a comprehensive residency program. Two of Houston Methodist's primary academic affiliates are among the nation's leading health care organizations: Weill Cornell Medicine and New York-Presbyterian Hospital.