Director of Quality

Job Title: Director of Quality

Department: Quality

Reports to: Chief Strategy Officer

Exemption: Exempt

Date Revised: 01/20/2024

Position Summary

Directs all aspects of the Quality department, including long term strategic planning, performance management of employees, budget management, agency wide-policy development and regulatory compliance.

Essential Functions

● The Director of Quality must be capable of directing and overseeing LOPA’s quality program functions to ensure agency adherence to company policy and industry standards. Quality management functions include: occurrence process, deviation process, development and management of controlled documents, internal audits and external audits.

● Using reasonable judgment, the Director of Quality must be capable of independently assessing LOPA’s quality program functions to determine an appropriate course of action.

● Must be able to utilize current organizational resources to determine next steps in the process.

● Must be able to effectively operate Google suite applications as well as learn and adopt computer skills to effectively update and communicate within programs such as LOPA’s referral management software and quality management software and hospital electronic medical records systems.

● Must be able to effectively and professionally communicate to internal and external audiences via different media, including, but not limited to, verbal, written and digital media.

● Assists in the development and execution of the LOPA’s strategic plans, developing goals and tactical plans to assist in meeting organizational objectives

● Ensures performance of assigned staff

○ Using data, evaluates performance of direct reports on a scheduled basis (as defined by HR) and provides appropriate feedback

*Establishes, communicates and continually assesses job responsibilities and performance expectations to assure mutual understanding and execution of desired results

*Ensures employee compliance with applicable policies and procedures, inclusive of HR policies

*Works with HR in the recruitment, interviewing and selection of applicants for department, including job description development and maintenance

*Works with HR in the development, growth and performance management of assigned staff

Job Role Expectations

● Establishes department goals, manages department performance and oversees departmental process improvement and strategic initiatives.

● Maintains and approves time cards and expense reimbursement of direct reports.

● Senior leadership of LOPA’s external audit program

○ Ensures agency is prepared for audit by external entities including, but not limited to, CMS, FDA, OPTN, and external vendors. Oversees all elements of agency preparation for and hosting of external audits.

○ Oversees the agency's response to any findings or observations from external audit. Supports agency’s compliance and improvement efforts through development of preventive actions for audit findings.

● Senior leadership of LOPA’s internal audit program

○ Audit internal processes to ensure alignment of all donation processes with regulatory requirements and organizational policy. Through internal audit, actively identify performance/process improvement opportunities to Executive leadership.

○ Advise and assist internal customers in use of data to identify outcomes not meeting goals and to design corrective actions and prioritize process improvement initiatives.

○ Through internal audits, continuously analyzes business processes to monitor implementation of performance improvements for effectiveness, stability and sustainability.

○ Ensure documentation of all tissue and organ recovery process elements aligns with regulatory standards, organizational policies, and stakeholder needs.

○ Ensure timely and appropriate communication of chart review findings to appropriate departmental staff and leadership in support of corrective actions and performance improvement efforts.

○ Through oversight of the Death Record Review process, ensure accurate, efficient, and timely completion of medical record reviews for missed referrals.

○ Ensure timely review of records in support of internal and external audits and data integrity.

● Senior leadership of LOPA’s occurrence and deviation management programs

○ Oversees the development, implementation and management of the mechanism by which LOPA identifies occurrences, such as complaints and adverse events, that require investigation to determine underlying causes; develops and implements an action plan; evaluates the effectiveness of the plan and, as needed, revises or continues with the plan based on the outcome of the evaluation.

○ In collaboration with the Director of Hospital Services, oversees LOPA’s deviation management process.

○ Responsible for investigation and resolution of Quality-related occurrences.

○ Ensure compliance of external reporting processes with regulatory standards, organizational policies, and stakeholder needs.

● Assists departmental leadership in development of, or revision to, policies and work instructions to improve organizational outcomes and ensure regulatory compliance and integrate operational excellence into the full spectrum of the donation process.

● Collaborates with department leadership and education to ensure new employees are informed of compliance requirements according to their job role and regulatory and/or standards compliance is built into their training programs.

● Works with the direct executive team in development of the budget for department(s)

● Leverage departmental resources in support of strategic goals of the agency.

● Participates in Governing Board and Advisory Board meetings, as requested.

● Conducts regular department meetings.

● Keeps direct supervisor updated on issues/challenges within the department through reporting or monthly meetings.

● Participates in assigned leadership meetings/training.

● Creates and fosters positive professional relationships for enhanced collaboration with internal and external customers, partners and stakeholders.

Organizational Expectations

● Upholds LOPA core values of selfless, authentic and passionate

● Serves as a role model for all employee and leadership written expectations

● Timely completion of all required educational training, tasks and SOP reviews by assigned due date

Supervisory or Advanced Responsibilities

Supervision of direct reports per Org Chart.

Role Progression

This role may be eligible for progression to an Executive position if one is made available. Promotion to Executive will be at the discretion of the Executive team.

Work Environment

● Possible exposure to communicable diseases, bloodborne pathogens, airborne illnesses, hazardous materials, pharmacological agents with little likelihood of harm if established health precautions are followed.

● May, at times, have exposure to blood, packaged organs and tissues for transplant and/or research in a hospital setting or while in the office.

● Possible mental and visual fatigue associated with detailed work.

● This position requires travel, as needed.

Physical Demands

● May require extended periods of sitting

● Requires driving when travel is needed

Work Hours

Full time, salaried position. Typical work hours are Monday-Friday 8:30am to 5:00pm with flex time

available at the discretion of the direct supervisor.

Education and Experience

● Bachelor’s degree in Public Health, Public Administration, biology, nursing or related field required.

● Minimum of five years quality assurance/performance improvement related experience in a healthcare setting. Knowledge of the principles of quality improvement, professional education, as well as critical care and transplantation.

● Comprehensive achievement in quality assurance and process improvement, strong project management skills.

● Analytical thinker, strong decision making and problem-solving capabilities.

● Working knowledge of human anatomy and function required.

● Previous experience working with regulatory agencies required. Experience in donation and transplantation preferred.

● Demonstrated leadership, excellent interpersonal, communication and presentation skills required. Ability to teach, train and work as a team member.

● Must be computer literate.

Knowledge, Skills & Abilities

● Ability to effectively manage people and processes.

● Ability to read, write, and comprehend instructions, with advanced skills in email and word processing.

● Working knowledge of Microsoft Office and Google Suite software.

● Ability to effectively present information in one-on-one and small group situations.

● Excellent verbal and written communication and interpersonal skills, an ability to listen to and balance, negotiate and work with a variety of internal and external stakeholders.

● Ability to think critically to solve problems.

● Highly organized, detail-oriented, reliable and flexible; thrives in a fast-paced environment; a driving force who manages toward clarity, finds solutions and is able to think strategically about the organization.

● Strong analytic capabilities with the ability to translate insights into strategies and plans that align with organizational goals and objectives.

● Skilled in establishing and maintaining relationships with internal and external contacts

● A team player with a flexible, collaborative and creative approach who can lead along the LOPA team.

● Ability to see the organizational goals as they relate to the “big picture.”

● Ability to maintain confidentiality

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