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Transplant Quality Coordinator

Job Ref: 25310

Talent Area: RN - Transplant

Houston Methodist Hospital
Houston, TX 77030

Area/Department: Transplant-Admin

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research.  Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 67 operating rooms and over 6,000 employees, Houston Methodist offers complete care for patients from around the world.

Job Summary

Reporting to the Director of Methodist Transplant Center, works collaboratively with medical/surgical staff, department leadership team members, and hospital leadership to ensure regulatory compliance with CMS Conditions of Participation for Transplant Centers, United Network of Organ Sharing (UNOS), Texas Department of Health Services (TDHS), and hospital accreditation agencies.  Assists program leadership with the processes of continuous assessment and improvement of the quality of care delivered to the pre and post transplant and VAD patient through monitoring of clinical outcomes of Transplant/VAD Services including organizing, collecting, validating, compiling, analyzing, and reporting results of these services/programs.   Oversees developing policies and procedures, and creating quality improvement processes associated with transplantation/VAD while facilitating adherence with regulatory agencies.  Supports and promotes the organization-wide quality program. 

Key responsibilities include:
I. Transplant Performance Improvement
II. Transplant Outcomes Management
III. Transplant Regulatory Compliance Management
IV. Professional Practice
Select the applicable age group(s) of primary customers/patients served by this position.

¿ Not applicable
¿ Neonate (Birth to 28 days)
¿ Infants/Toddlers (29 days to 18 months)
¿ Toddler (18 months to 3 years)
¿ Preschooler (3-6 years)
¿ School Age (6-12 years)
¿ Adolescence (12-18 years)
¿ Young Adult (19-40 Years)
¿ Middle Adult (40-65 Years)
¿ Mature Adult (65 years and older)

System and department specific ICARE values

INTEGRITY: We are honest and ethical in all we say and do.
COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
ACCOUNTABILITY: We hold ourselves accountable for all our actions.
RESPECT: We treat every individual as a person of worth, dignity, and value.
EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

Duties and Responsibilities are cross-referenced to the hospital¿s Pillars of Excellence and will be transferred to the Performance Evaluation.

1. Communicates in an active, positive, and effective manner to all health care team members, physicians and staff who are part of the multidisciplinary transplant program in order to facilitate quality activities and regulatory compliance goal attainment. (EF)
2. 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.  (EF)
3. 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, TJC, and CMS. (EF)
4. Serves as a resource person/mentor, and actively promotes professional practice within the service.  Serves as a clinical resource to staff members by providing quality/compliance education to all staff members in order to promote individual staff member accountability and responsibility. (EF)
5. Demonstrates ability to work with all disciplines to achieve a common goal and promotes positive group dynamics as a leader and team member.  Proactive and effective in developing and maintaining collaborative relationships with physicians, management and staff.  (EF)

1. 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.
2. Contributes to meeting departmental and organ program financial measures on departmental dashboard. 

1. Promotes department/service line understanding of the Transplant CMPI program. (EF) 
2. Facilitates a multi-disciplinary 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. (EF)
3. Implements quality improvement projects involving data collection, validation, analysis, and reporting.   Identifies opportunities for improvement based on data analysis.  (EF)
4. In collaboration with administrative and physician leaders, develops and implements reporting processes regarding clinical quality across all organ transplant/VAD programs. (EF)
5. 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.  (EF)
6. Oversees the development, implementation, evaluation and revision of order sets, policies, and other documentation.  Monitors documentation on patient record based on standards and policies. (EF)
7. Monitors outcomes of process/system changes and reports variances to appropriate management and staff. (EF)
8. Updates departmental 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. (EF)
9. Contributes to meeting departmental and organ program targets for quality and safety, on departmental dashboard.

1. Supports and assists management in coordinating and facilitating CMPI committee meetings and maintaining the CMPI documentation for the transplant center.  (EF)
2. Maintains ongoing clinical data in support of assessment and improvement of quality of care. Prepares internal or external clinical data requests. (EF)
3. Coordinates and 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.  (EF)
4. Supports and participates in departmental patient experience initiatives.  Demonstrates the components of I CARE values system. 

1. Maintains knowledge of current trends in transplant nursing and health care delivery.
2. Demonstrates continuous learning and growth; identifies own learning needs and actively seeks educational opportunities, both formal and informal, to meet those needs.  Applies evidence-based practice to daily work, such as reviewing the professional literature and attending professional meetings and sharing with colleagues.
3. Supportive of change initiatives.  Adapts to unexpected changes.  Acts as change agent.

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Houston Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.

Registered Nurse, Bachelor's Degree required; Master's Degree preferred

Minimum 5 years nursing experience.  Transplant or Quality experience preferred
Experience with managing regulatory reporting and audit processes 
Project management experience preferred

Registered nurse with current Texas license

¿ Demonstrates strong knowledge of organ failure clinical processes.
¿ Demonstrates knowledge of hospital or specialty services regulatory reporting, accreditation, and audit processes.
¿ Demonstrates knowledge and application of process improvement tools and techniques (statistical process control tools and team tools).
¿ Ability to define problems, collect data, establish facts and draw valid conclusions and evidence performance improvement via measurable results.
¿ Ability to enter and abstract data using personal computer, as well as the ability to utilize data to facilitate the improvement and change in processes  (Access, MS Excel, MS Word, PowerPoint).  Able to navigate transplant applications and data systems (UNET, DonorNet, Tiedi).
¿ Extremely well-organized and detail oriented, self-directed.
¿ Excellent interpersonal skills required to deal with diverse multidisciplinary team members.
¿ Excellent oral and written communication skills required.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.