Transplant Quality Coordinator

Transplant Quality Coordinator at Houston Methodist Hospital summary:

The Transplant Quality Coordinator, a registered nurse at Houston Methodist, ensures regulatory compliance with transplant healthcare standards set by CMS, UNOS, and state authorities. This role involves continuous quality assessment and improvement of transplant and VAD patient care through data analysis, policy development, and collaboration with clinical and administrative teams. The coordinator also manages regulatory reporting, supports accreditation efforts, and leads quality improvement initiatives to enhance patient outcomes and departmental performance.

• 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 teamwork approach in all interactions with peers and team members and providing 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 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, assist 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. Stay 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 on-going basis.

• Bachelor's degree or higher from an accredited school of Nursing

• Five years of nursing experience, which includes two years Transplant or Quality experience
  

• Experience with managing regulatory reporting and audit processes
  

• Project management experience preferred
  

Keywords:

transplant quality coordinator, registered nurse, regulatory compliance, CMS conditions of participation, UNOS, quality improvement, clinical outcomes, data analysis, patient care, hospital accreditation