Quality Manager - Transplant (1.0 FTE, Days)

Category: Quality
Job Type: Full-Time
Shift: Days
Req: 12043
FTE: 1


1.0 FTE, 8 Hour Day Shift

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

The Transplant Quality Manager is responsible for planning, coordinating and monitoring the effectiveness of clinical care and services based on quality outcomes, cost effectiveness, and patient centeredness. This position provides project management and facilitation expertise to negotiate timelines and priorities for projects, coordinate action plans and monitor results that are consistent with overall strategic and transplant specific imperatives. In conjunction with appropriate Transplant and organizational leadership, this position supports the development, coordination, implementation and evaluation of quality and performance improvement, patient safety, and clinical effectiveness initiatives within the Transplant Center through facilitation and co-leadership of multidisciplinary teams. The Transplant Quality Manager identifies opportunities for improvement based on evidence based practices, regulatory and accrediting agency requirements, and monitoring of high risk, high volume and/or problem prone processes.

Additional key areas of responsibility include:

Examining effective Models of Care delivery for opportunities for optimization and to decrease waste within the systems of care.

  • Identifying opportunities for improvements based on evidence based practices, regulatory and accrediting agency requirements, and data analysis of high risk, high volume and/or problem prone processes. 
  • Partnering w/Transplant Outcomes Analyst to ensure validity of Transplant data.
  • Organizing and facilitating relevant task forces or work groups, review of evidenced-based literature/benchmarks, and suggesting revisions/additions to the indicators for monitoring and evaluation of quality and appropriateness of care.
  • Ensuring the accuracy and completeness of the databases and metrics used for quality tracking and improvement efforts; maintaining the scorecards and other reports used for Quality Improvement.
  • Performs and coordinating activities relating to ensuring the Transplant Center’s  compliance with requirements of external agencies in the area of quality and accreditation surveys/inspections, specifically those related to Transplant: The Joint Commission (TJC), CMS, the United Network for Organ Sharing (UNOS)

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.

Employees must abide by all TJC requirements including but not limited to sensitivity to cultural diversity, patient care, patients’ rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).

Performance Improvement Activities -

  • Provides support in identifying, designing and implementing new processes and clinical care, based on evidence, to continually improve patient care and outcomes and to achieve performance targets.
  • Provides expertise in understanding and using SCH data models & systems and acts as resource in the interpretation and use of data generated and utilized by the department.  Assures continuous tracking of quality data in the transplant databases, monitors ongoing data integrity processes.
  • Evaluates data, makes judgments, and recommendations regarding quality improvement work, including but not limited to resource utilization, physician practice patterns, and clinical pathway effectiveness. Coordinates development and preparation of quality report cards/scorecards.
  • Coordinates with the medical and surgical directors the regular reporting of transplant quality data to the appropriate hospital committees. Prepares or assists with the presentations for those meetings.
  • Organizes and co-facilitates multi-disciplinary teams to successfully implement performance improvement initiatives to achieve program quality improvement goals.
  • Annually coordinates a review of the QAPI indicators defined for each organ program and makes recommendations for revisions.
  • Oversees the ongoing medical record reviews, including reviews of documentation required for UNOS and CMS.
  • Collates and submits data related to these reviews to the leadership team and hospital departments as requested.

Accreditation and Regulatory Compliance

  • Facilitates and coordinates accreditation and regulatory compliance.
  • Maintains current knowledge of requirements related to CMS Conditions of Participation, The Joint Commission, UNOS and the California Department of Public Health.
  • Provides regular updates to managers and ongoing education to staff as requested by the management staff.
  • Responsible for supporting management staff to achieve and maintain accreditation and regulatory compliance within Transplant Services.
  • Assists in the preparation of action plans.
  • Assists managers and staff to assure continuous readiness for survey with policy and procedure review and revision, mock survey drills, and ongoing education.
  • Develops/revises/implements plans for response to unannounced surveys/visits.
  • Coordinates scheduling of announced visits/surveys. Coordinates preparation of UNOS reports including annual personnel report, changes in key personnel, and reports requested by the Membership and Professional Standards Committee.
  • Monitors and tracks compliance with UNOS requirements for data submission.
  • Alerts the management team if there is not full compliance with the requirements.

Patient Safety

  • Provides leadership for creating a culture of patient safety and works with various constituencies to ensure compliance to the National Patient Safety Goals.
  • Facilitates improvement related to patient safety and transplant adverse events, including identification, action planning and ensuring discussion at quality meetings.

Patient Experience Activities

  • Understands importance of providing exceptional patient experience and supports facilitation of improvement efforts aimed at such.
  • Performs other related and incidental duties as needed or assigned.

Minimum Qualifications

Education: Master's degree in a work-related discipline/field from an accredited college or university (such as Quality Improvement, Quality Management, Healthcare Management, Public Health, Nursing or Business Administration).   

Experience: Five (5) years of progressively responsible and directly related work experience in quality improvement, patient safety and/or external regulatory/accrediting agencies compliance activities in support of improving clinical effectiveness and patient care/outcomes.  Five (5) years of clinical experience with transplant patients and two (2) years of  general experience with transplant programs preferable.

License/ Certification: None required.

Knowledge, Skills, and Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

  • Knowledge of the principles and practices of quality improvement, including, in particular, their application in an academic medical center.

  • Knowledge of and ability to apply multiple performance improvement methodologies and tools to projects (e.g., A3 thinking, PDCA, value stream and process mapping, root cause analysis, etc.).

  • Knowledge of computer systems and software used in functional area.

  • Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation.

  • Knowledge of project management and change management methodologies and tools.

  • Knowledge and proficiency in the use of Microsoft Office Suite of applications, clinical documentation systems (preferably EPIC), as well as decision support systems, such as Access, or other relational databases.

  • Ability to utilize the Clinical Effectiveness framework to ensure performance improvement initiative focus on improving outcomes, appropriateness of care, patient centeredness and value.

  • Ability to speak, read, write, and understand English effectively at a level appropriate for the safe and effective performance of the job.

Physical Requirements and Working Conditions

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.


Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.