Under limited supervision, plans, coordinates, leads, and monitors quality improvement and patient safety initiatives for ambulatory transplant services. Accountable for the overall quality of procedural care provided at UMMC as well as compliance with, CMS, Joint Commission Standards and associated other regulations.

Principal Responsibilities and Tasks The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Plans, organizes and directs departmental quality improvement and patient safety activities. Conducts studies of identified problem areas in accordance with the Quality Assessment Performance Improvement Plan of procedural care services.

A. Works collaboratively with the VP Procedural Care Services, the Directors of Nursing, Managers to identify quality improvement and patient safety priorities.

B. Collects reviews and analyzes data related to quality improvement and clinical care, and identifies strategies and opportunities for sustained practice work flow improvements.

C. Maintains departmental dashboards.

D. Routinely reviews area data for accuracy and prepares documentation for leadership review.

E. Prepares statistical reports as required to identify trends or patterns that present an opportunity to improve the quality of patient care and services for transplant patients in the ambulatory setting.

2. Revises patient documentation forms and consents as indicated.

3. Shares trends, patterns or issues identified during concurrent reviews, providing explanation and details regarding monthly quality assurance reports, and/or obtains medical records or additional information to be discussed.

4. Prepares staff and coordinates site surveys with regulatory agencies.