Quality Manager

Valhalla, New York, Job Summary: The Manager of Quality, Transplant Services will be responsible to manage and facilitate quality improvement activities for the Transplant Service Line. Taking a systematic and data-driven approach, incumbent will monitor the quality of services and outcomes to ensure that highest caliber of care is rendered to the patients served by the Transplant programs. The Manager will work with the Director to assist inleading efforts to study and improve processes as well as identify areas of opportunity to address underlying causes of systemic problems or barriers to improvement. Responsibilities: Uses Root Cause Analysis (RCA) to fully appreciate the underlying causes of adverse outcomes and implications of change. Incumbent will review charts to ascertain relevant fact patterns and collaborate with physician staff to create event synopses. Identifies the need and organizes RCA events. Researches evidence-based practices and benchmarks. Identifies key performance indicators to monitor care processes and outcomes. Collects and presents data to track performance. Proactively monitors to stay abreast of regulatory changes.

Develops systems to implement new regulations and monitor compliance. Writes and modifies programs’ policies and procedures, ensuring that they are updated as necessary to remain in compliance with regulatory mandates and that they reflect current practice. Performs audits to ensure documentation complies with regulatory requirements. Develops correctives action plans to address gaps in documentation. Leads effort to prepare for all regulatory surveys. Collaborates with Program Leaders to draft regulatory responses. Gathers information to identify areas in need of improvement. Develops process improvement projects (PIP) using the Deming Methodology (PDCA). Engages the teams in PIP efforts. Monitors for improvement and collects data to assess efficacy of interventions.

Monitors adverse event reporting system; Investigates events and crafts responses. Responds to request for information from internal as well as external parties seeking data regarding Program performance. Develops educational material and trains stakeholders across the hospital on compliance with regulatory requirements. Fosters a culture of quality improvement and patient safety. Maintains documentation related to all QA and PI efforts including not limited to: M&Ms, Selection Committees, PIP meetings, and RCAs. Serves as liaison between Transplant Service Line and Hospital Quality and Safety Department. Qualifications/Requirements: Experience: Experience with solid organ transplant or clinical background, required. Education: Bachelor’s Degree, required. Special Requirements: Must be able to function as part of small and large teams Possess skill as a critical thinker Able to manage in a highly complex environment About Us: WMC Advanced Physician Services PC

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