• Employment Type: Full Time
• Shift: Days
• Hours: 5 (8) or 4 (10)
• Location: Boston, MA

Job Description

1. GENERAL SUMMARY:

The Transplant Quality and Regulatory Administrator reports to the Director of Solid Organ Transplant Services.

The Transplant Quality and Regulatory Administrator is responsible for the regulatory compliance and patient safety aspects of the Transplant Program to foster the development of a high reliable organization. Facilitates and participates in the implementation of the multidisciplinary Solid Organ Transplant and VAD Programs, hospital and system wide Clinical Quality and Patient Safety Performance Improvement Program. This healthcare professional coordinates the planning, monitoring and evaluation of compliance with the Department of Public Heath, Center for Medicare Services (CMS), United Network for Organ Sharing (UNOS) and other regulatory agencies as required. Participates in planned and unplanned regulatory visit activity. Promotes collaborative practice among departments/services for improved clinical outcomes, processes of care and regulatory compliance.

Improvement

• Oversees and coordinates efforts of the Transplant Program Clinical Quality and Patient Safety Performance Improvement Program.
• Facilitates the identification of opportunities for improvement and assist in the design and ongoing measurement of performance indicators and outcomes.
• Assists in planning, reviewing, and implementing activities related to the organizational and Transplant Program goals and objectives including Quality and Safety Goals.
• Collaborates with key stakeholders, peers and other departments to facilitate and monitor the timely completion of agreed upon corrective action plans arising from survey findings, root cause analyses or other sources.
• Plan, coordinates, and reports Adverse Event Reviews for solid organ transplant and VAD services.
• Partners with physician leadership and the department of surgery to coordinator Transplant Mortality and Morbidity conferences.
• Facilitates and participates in the Transplant Program and VAD improvement initiatives as appropriate.
• Monitors and maintains current transplant policies and guidelines for Heart, Kidney, Liver, and VAD services.
  

Data/Measurement Systems

• Supports an information system for quality and regulatory management data collection, data aggregation, and data analysis as well as the maintenance of an inventory of quality improvement activities including safety solution measures of success.
• Monitors and displays statistical data for quality reports and evaluations.
• Serves as internal resources for the quality and performance improvement process including data measurement, tool development, chart review, improvement strategies and education on improvement methodologies. Serve as a liaison with regulatory data abstraction and reporting.
• Collaborates with the Data and Informatics Administrator to ensure accurate Epic dashboards are available and reviewed.
• Reviews monthly XYN QAPI data and provides summary at monthly organ specific QAPI.
• Collaborates with the Data and Informatics Administrator to review SRTR data release and ensure information is communicated to the transplant program.
  

Regulatory & Accreditation

• Uses knowledge of standards of accreditation and regulatory agencies to assist with assessment of compliance. Conduct ongoing assessment of standards compliance including observation, interview and medical record review to engage staff and assess compliance.
• Participates in the preparation, planning, coordination and oversight of planned and unplanned regulatory survey and reporting by The Joint Commission, DPH, CMS, UNOS and other regulatory agencies as required.
• Monitors for changes in CMS or UNOS regulations as they pertain to solid organ transplant. Assesses the impact of policy change and collaborates with stakeholders to develop implementation and monitoring plans.
  

Continuous Learning

• Develops and facilitates education workshops, meetings or conferences focused on
  improvement methodologies and regulatory compliance with high impact on the Transplant Program and/or participants; coordinates logistics, scheduling and participant communications.

• Develops and writes educational material and communication for distribution for quality and regulatory purposes.
  

General

• Participates as a member of the hospital Quality Performance and Improvement Committee.
• Supports and maintains the quality structure which includes all quality related transplant committees including preparation of documentation and flow of material.
• Supports the hospital QAPI structure, departmental committees, performance improvement taskforces and organizational improvement teams as appropriate.
• Assist with the investigations and responses to quality of care inquiries arising from other third party sources and patient complaints/grievances.
• Interacts and maintains liaison with students, faculty, staff and outside/community agencies or committees in facilitating program objectives.
• Maintains effective communication and working relationships with a wide variety of staff (hospital, medical, ambulatory, behavioral) to support and facilitate quality -related initiatives.
• Performs other related duties.
• The Transplant Quality and Regulatory Administrator will be responsible for supervising TIEDI data entry and processes and policies associated with data entry into all transplant and VAD related databases including UNOS, CIBMTR and INTERMACS.

II. PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:

• Regular monitoring and tracking of the department policies and procedures (P&P) to ensure regulatory compliance with UNOS, FACT, Joint Commission and CMS.
• Oversight of maintaining and storage of regulatory documents and outcomes
• Responsible for overseeing the creation and maintenance of all transplant procedures; ensure they comply with transplant regulatory requirements
• Responsible for overseeing continuous audits for regulatory compliance.
• Responsible for identifying corrective action plans for deviations and adverse events, as deemed necessary.

• Quality Activities and report to the regulatory committee and QAPI/Hospital Quality and Medical Board:
• Prepares and tracks all regulatory audits and dashboards for reporting at committee meetings
• Responsible for overseeing the maintenance of the Heart, Liver and Kidney transplant summary and dashboard (via XYN Management) to track volume and quality measures this is the primary source of all transplant data as needed by internal and external users.
• Collaborates with Quality Improvement and Regulatory Affairs to monitor clinical outcomes and perform audits for the Transplant Quality Improvement Committee and any corrective action plans as requested by internal and external agencies.
• Survey Readiness preparation including CMS accreditation, FACT accreditation, VAD certification as well as coordination of routine UNOS site surveys. Lead audit preparation activities in conjunction with the Quality and Patient Safety Department, coordinates all activity during on-site audits and coordinate the development and monitoring of post-audit corrective action plans.
• The incumbent will be responsible for management of staff related to data entry into transplant regulatory Systems including UNOS, CIBMTR and INTERMACS. This includes developing data entry policies as well as oversight of the process.
• Responsible for communication with regulatory bodies including response to requests for allocation analyses, communication with surveyors, requests for data and communication through the patient safety portal.
• Responsible for the coordination of the annual OPTUM and UNOS Transplant RFIs; gather and analyze data to complete surveys in a timely manner; work collaboratively with faculty to ensure optimal representation of the transplant program to payers.

III. JOB REQUIREMENTS:

1. JOB KNOWLEDGE AND SKILLS:

• Minimum of two years of relevant quality improvement, process improvement and/or regulatory compliance work experience
• Knowledge of transplant regulatory requirements (CMS conditions of participation for transplant centers and UNOS bylaws and policies, FACT accreditation standards)
• Strong analytical and/or operational problem solving skills; demonstrates ability to conduct and interpret quantitative/qualitative analyses and makes recommendations for improvement/changes.
• Knowledge of Word, Excel, Access, and PowerPoint software programs or equivalents. Ability to run analytical (excel, pivot and other) reports and summarize information.
• Excellent communication skills (oral, electronic, and written).
• Ability to demonstrate excellent judgment, attention to process and detail.
• Discretion, confidentiality, tact, and ability to deal with sensitive issues. Previous project lead or project management experience.
• Able to prioritize multiple deadlines and dependent activities.
• Ability to work independently and in a team environment.
• Database data entry and/or management experience preferred.
• Supervisor experience preferred
• Lean or Six Sigma training preferred.

EDUCATION:

1. Bachelors degree (nursing, health care administration, public health, business administration or a related field)
2. Masters degree or equivalent experience in Nursing, Business Administration, Health Care Administration or other related field

V. WORKING CONDITIONS/PHYSICAL DEMANDS:

• Normal office environment

AMERICANS WITH DISABILITIES STATEMENT:

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. New England Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

All your information will be kept confidential according to EEO guidelines.

COVID-19 POLICY:

Please note that effective October 1, 2021, as a condition of employment at Tufts Medical Center, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.

AMERICANS WITH DISABILITIES STATEMENT:

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Tufts Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

COVID-19 POLICY:

Please note that effective October 1, 2021, as a condition of employment at Tufts Medical Center, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.