Director, QI, Regulatory Affairs, and Education
Job Requisition: 13083
Department: Trnsplt-Admn & Post Surg
Geographic Region: Washington, DC
Facility: MedStar Georgetown University Hospital
Schedule: Full Time
Shift: Day Shift
Hours per Week: 40.00
Location: Washington, DC
MedStar Georgetown University Hospital is a not-for-profit, acute-care teaching and research hospital with 609 beds located in Northwest Washington, D.C. Founded in the Jesuit principle of cura personalis—caring for the whole person—MedStar Georgetown is committed to offering a variety of innovative diagnostic and treatment options within a trusting and compassionate environment.
MedStar Georgetown's centers of excellence include neurosciences, transplant, cancer and gastroenterology. Along with Magnet® nurses, internationally recognized physicians, advanced research and cutting-edge technologies, MedStar Georgetown's healthcare professionals have a reputation for medical excellence and leadership.
General Summary of Position:
Provides management, coordination, direction, oversight and other support as required to a wide range of quality/ performance improvement, regulatory compliance, and staff education related activities for the Georgetown Transplant Institute. These activities include, but are not limited to quality improvement activities in support of clinical activities; development and implementation of policies and procedures related to quality improvement and regulatory compliance; conducts quality of patient care audits of transplant patients at MedStar Georgetown University Hospital and MedStar Washington Hospital Center; participates in the development of information on clinical transplantation topics for education of clinical staff in the Georgetown Transplant Institute as well as inpatient nursing, ancillary staff and other associates involved in the care of transplant patients at MGUH and MWHC; and ensures compliance with all data management and reporting requirements as set by CMS, Joint Commission, UNOS, state and local government agencies. These functions are coordinated with the department head and are performed in accordance with all applicable laws and regulations and MedStar Georgetown University Hospital’s philosophy, policies, procedures and standards.
- EDUCATION AND/OR TRAINING REQUIRED: BS degree, preferably in a health care related or management curriculum.
- LICENSURE AND/OR CERTIFICATION: RN preferred. If a registered nurse, must be a graduate of an accredited school of nursing and hold a current DC license as a registered nurse.
- EXPERIENCE: Five to seven years of solid organ transplant related experience, preferably in a large healthcare organization.
- SPECIAL KNOWLEDGE/SKILLS/ABILITIES: Excellent knowledge of Joint Commission (JC) standards and ambulatory practice standards and operations. Ability to work independently using excellent judgment, clinical skills and to handle sensitive medical matters in an appropriate manner. Excellent counseling and mentoring skills required. Must be able to manipulate and analyze statistical data. Must be able to work with diverse groups of people and with all levels of personnel within the hospital.
- Consideration will be given to an appropriate combination of education/training and experience.
Primary Duties and Responsibilities:
- Plans and manages the implementation, monitoring, and evaluation of a comprehensive quality assessment and improvement program in the outpatient settings of the MedStar Georgetown Transplant Institute (MGTI) and collaborates with inpatient, perio-op and quality department team members that impact transplant patient continuity of care.
- Identifies specific transplantation care quality issues and develops recommendations for improvement activities as needed to be addressed within the MedStar Georgetown Transplant Institute (MGTI)
- Communicates performance improvement (clinical and operational) initiatives and helps facilitate practices develop and implement action plans and achieve and sustain improvements in performance in transplantation clinical settings.
- Develops improvement goals with industry and UHC benchmarks in collaboration with clinical leaders, and monitors the changes in operations in the MGTI.
- Collaborates in the development of tools, sharing of ideas and the address of health literacy and cultural competency and the implications for patient compliance and well being.
- Provides direct supervision to data coordinators and conducts mid-year and annual performance evaluations.
- Oversees data coordinator submissions of periodic and other required data reports to UNOS.
- Organizes clinical and administrative leaders to draft responses to regulatory concerns, plans of correction in a timely manner.
- Conducts internal audits of the quality of care provided by attending physicians, fellows, residents and midlevel providers for a variety of disease states.
- Analyzes quality, safety and outcomes data to identify trends and proposes interventions to clinical leaders as needed to improve patient care services in transplantation.
- Facilitates and participates in multidisciplinary workgroups to effect systematic resolution of quality and patient safety related issues.
- Serves as a point person for quality improvement and patient safety related activities. Monitors and assists the Georgetown Transplant Institute in the development of performance improvement initiatives.
- Participates in the development of responses to the requests, inquiries and survey comments from auditors of accrediting bodies such as CMS, Joint Commission, UNOS and District of Columbia Department of Health. Assists with the coordination of JC, Department of Health, and other accreditation surveys
- Ensures that MGTI clinical practices are consistent with the Joint Commission standards for MGUH and MWHC. Active participation with the Quality Improvement departments for the MedStar Health hospitals in the DC region.
- Provides ongoing continuing education opportunities to the clinical staff, Monitors all staff compliance with hospital required competency modules. Provides educational support to providers regarding CMS Meaningful Use criteria.
- Serves as a point person for new physician and mid-level provider credentialing and license renewal.
- Participate in the “On-call” pool as needed during times of staff shortages, operational emergencies, and/or inclement weather.
- Participates with the MedStar Health Community Services division to ensure that all MGTI related community service is accounted for on the quarterly Community Benefits Report.
- Oversee new associate orientation and training for all non-administrative positions.
- Performs other duties and responsibilities that are appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and is not to be considered as all-inclusive.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.
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