This position manages all aspects of quality for PCH Transplant, Dialysis & Apheresis. The position ensures the ongoing compliance with all relevant regulatory agencies (CMS, OPTN, FACT, and DMV) through the establishment of a department-wide quality management program. Ensures that quality reports are developed to establish/maintain focus on delivering a mature quality culture. Administrative duties include the selection and supervision of personnel, budget management direct supervision of quality and research/data staff. This position receives supervision of completed work activities from the VP Transplant & Dialysis.

1. Effectively Manages Transplant, Dialysis & Apheresis Quality Management activities.
   • a. Customizes the department quality improvement and safety reports on a regular basis so the information relayed will be pertinent and timely to each audience reviewing the data.
   • b. Develops and implements solutions to improve services and creates methods to quantify these levels of improvement to demonstrate the potential level of quality achieved.
   • c. Recognizes, monitors, and analyzes trends in department activities for the purposes of improving process flow, enhancing productivity, and/or increasing patient and employee satisfaction.
   • d. Is familiar with LEAN and Six Sigma tools and concepts for process improvement. Will use these concepts to help drive and measure change, improvement, and reach targeted quality goals. Can engage the team and teach these concepts.
   • e. Assists in developing and writing policies and procedures, as pertinent to job duties.
   • f. Serves as a liaison between department and other hospital areas to coordinate all quality improvement activities for optimal efficiency and effectiveness; recommends process changes as appropriate.
   • g. Uses effective process improvement techniques to identify outliers in all processes of department services, to include communication, reporting and billing.
   • h. Advises and influences leadership within transplant, dialysis and apheresis on regulatory changes and state-of-the-art advances in systems, technologies, data management, methodologies, the latest industry trends, developments, and best practices.
2. 2. Manages programmatic implementation of accreditation standards and provides continuous process analysis to enforce regulatory requirements.
   • a.Responsible for the oversight and implementation of continuous survey readiness within each area of the department.
   • b.Ensures that audit plans address essential elements required by survey agencies
   • c.Is familiar with regulatory guidelines and changes within each area of the program including, but not limited to: FACT, OPTN, CMS and State of Arizona.
   • d.Partners with colleagues across the organization to ensure compliance with accreditation and licensure requirements
   • e.Is point person for all survey’s related to solid organ transplant. Is leadership support for quality consultants in BMT, Apheresis and Dialysis surveys.
   • f.Responsible for ensuring corrective actions plans required are developed, submitted, and adhered to.
   • g.Is safety point of contact for solid organ transplant for the organization.
   • h.Is OPTN Membership and Professional Standards (MPSC) delegated point of contact for the organization.
3. 3. Develops and supervises staff through provision of timely feedback, use of appropriate HR policies and tools to facilitate and ensure the ability of staff to achieve highest level of professional growth and desired performance standards. Provides employee performance evaluations and coaching.
   • a.Responsible for employee recruitment, performance evaluation and management
   • b.Responsible for staff development
   • c.Develops a strong culture of teamwork to ensure the quality of daily operations, effective interdepartmental collaborations, and the timely achievement of objectives.
4. 4. Ensures adherence to departmental operating and capital budgets; monitors productivity of areas of responsibility to meet benchmark metrics.
   • a.Generates budgets in assigned cost centers relative to transplant quality and compliance
   • b.Develops and ensures adherence to time lines and work plans for transplant quality and process improvement.
5. 5. Leads solid organ transplant quality, performance improvement and compliance programs.
   • a.Directly responsible for the quality plan, meetings, process improvement and safety event monitoring/investigations within some of the solid organ transplant programs.
   • b.Responsible for all MPSC correspondence development and submission in partnership with the VP of Transplant.
6. Performs miscellaneous job related duties as requested.

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

Values

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable