Quality/Performance Improvement Manager

Posted Date 60 minutes ago(10/19/2020 10:40 AM)
Requisition ID
Nursing - Outpatient
Position Type
Regular Full-Time
ICE TXPSL Admin Office
Day Shift
Post End Date


In collaboration with the Medical Director for Transplant, Director for Transplant Services, medical, nursing and multi-disciplinary transplant team members, the Manager for Transplant Quality, Regulatory Compliance and Data Integrity is responsible for the development and oversight of the quality assessment and process improvement activities with a goal to improve patient safety and produce optimal clinical outcomes.  In addition the Manager will ensure patient care is provided in accordance with departmental policies, procedures and regulatory agencies including The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS) and the Organ Procurement and Transplant Network (OPTN/UNOS). Other integral responsibilities include assurance of data integrity by validation of internal database entries and accurate, timely submission of information to UNOS, as well as mining reports from the Scientific Registry for Transplant Recipients (SRTR) to establish adverse outcome trends and opportunities for revision of clinical processes leading to improved graft and patient survival.


The University of Arkansas for Medical Sciences (UAMS) has a unique combination of education, research, and clinical programs that encourages and supports teamwork and diversity.  We champion being a collaborative health care organization, focused on improving patient care and the lives of Arkansans.  


UAMS offers amazing benefits and perks:

  • Health: Medical, Dental and Vision plans available for staff and family
  • Holiday, Vacation and Sick Leave
  • Education discount for staff and dependents (undergraduate only)
  • Retirement: Up to 10% matched contribution from UAMS
  • Basic Life Insurance up to $50,000
  • Career Training and Educational Opportunities
  • Merchant Discounts
  • Concierge prescription delivery on the main campus when using UAMS pharmacy

Salary: offered commensurate with experience


KEY RESPONSIBILITIES (list primary functions of the position with the percent of time generally allocated to each; percent of time must equal 100%)


Quality Assessment/Process Improvement (40%) 

  1. Promote, implement and monitor quality assurance and process improvement activities within the Transplant Department and in other clinical areas for the transplant patient population. (Inpatient, OR and Outpatient Clinics)
  2. Co-chair the Solid Organ Transplant Quality Committee, establish agendas and produce minutes/action plans from each meeting.
  3. Maintain adverse event log with appropriate documentation for investigation and action plans.
  4. Understand the transplant process and patient journey through referral, evaluation, listing, transplant and post-transplant phases in order to improve efficiencies, patient satisfaction and patient safety.
  5. Prepare and review on an annual basis, the Transplant Quality and Performance Improvement (QAPI) plan and all scorecard metrics with Medical Directors and clinical staff.
  6. Report QAPI activities/data to Patient Safety Council on a quarterly basis.
  7. Ensure staff is educated and follows established guidelines for reporting an adverse event. Promote a culture of patient safety.
  8. Participate in the analysis of any adverse event and implement changes in relevant policies and practices to prevent repeat incidents.
  9. Provide direction and undertake actions that result in performance improvements utilizing the plan, do, study, act (PDSA) process and track performance to ensure that improvements are sustained.


Regulatory Compliance (30%) 

  1. Serve as expert resource and staff mentor/educator to ensure regulatory requirements are met for all Federal and State agencies relative to transplant program operations including, but not limited to: The Joint Commission (TJC), Organ Procurement and Transplant Network (OPTN/UNOS) and Centers for Medicare and Medicaid (CMS).
  2. Ensure on-going survey readiness by monitoring chart audit tools and developing methods for electronic storing of pertinent data reviewed by regulatory agencies.
  3. Ensure patient care is provided in accordance with departmental policies, protocols and regulatory requirements through annual review and as indicated with changes by agencies to their policies and interpretive guidelines. 
  4. Assist with the preparation of UNOS and CMS documents required for responses to surveys, applications for UNOS surgical and medical directors and new programs.


Data Integrity (30%) 

  1. Responsible for the security, integrity and quality of data for patient medical record keeping within departments’ transplant database.
  2. Thorough understanding of all UNet forms and the fields critical for risk stratification utilized by SRTR.
  3. Improve the accuracy and timeliness of all record-keeping, UNet data collection and reporting to regulatory agencies through staff education upon hire and ongoing.
  4. Analyze Scientific Registry for Transplant Recipients (SRTR) reports for accuracy and identify adverse trends leading to graft failures or patient deaths in order to implement changes to clinical practice which could improve outcomes.
  5. Produce forecasting reports for SRTR outcome data and identify any risk for falling below acceptable thresholds.


Other duties as assigned.


Bachelor’s degree is required

Registered Nurse with current Arkansas license, BCLS certification

Minimum of 5 years healthcare experience as an RN with 2 years required as a transplant nurse coordinator with in-depth understanding of UNOS and CMS regulations  or Minimum 5 years healthcare experience as an RN and 2 years experience in an acute care hospital quality department role working with clinical services to monitor quality and lead process improvement projects

Certified Clinical Transplant Coordinator (CCTC) preferred

Certified Professional in Healthcare Quality (CPHQ) preferred


This position is subject to a pre-employment criminal background check.  A criminal conviction or arrest pending adjudication alone shall not disqualify an applicant. Any criminal history will be evaluated in relationship to job responsibilities and business necessity.  The information obtained in these reports will be used in a confidential, non-discriminatory manner consistent with state and federal law. 



UAMS is an Affirmative Action and Equal Opportunity Employer of individuals with disabilities and protected veterans and is committed to excellence




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