The Director of Transplant Quality, Compliance and Operational Efficiency is responsible for leading quality assurance, regulatory compliance, and process improvement initiatives within our transplant center. This role is crucial in ensuring our program meets or exceeds national standards while optimizing patient outcomes and operational efficiency. Additionally, the Director oversees the staff education program and the transplant Information Systems (IS) team, ensuring comprehensive management of all quality, compliance, and operational aspects of the transplant program.

• Develop, implement, and maintain a comprehensive quality management system for the transplant program
• Lead continuous quality improvement initiatives across all aspects of transplant care
• Analyze quality metrics and outcome data to identify areas for improvement
• Collaborate with clinical teams to implement best practices and evidence-based protocols
• Ensure compliance with all relevant federal, state, and local regulations, including UNOS/OPTN policies
• Oversee the preparation and maintenance of all required documentation for regulatory inspections and audits
• Stay informed about changes in transplant regulations and implement necessary program adjustments
• Manage relationships with regulatory bodies and accreditation organizations
• Identify and implement process improvements to enhance operational efficiency
• Optimize resource allocation and utilization across the transplant program
• Develop and monitor key performance indicators (KPIs) for operational efficiency
• Oversee the development and implementation of comprehensive education programs for transplant staff
• Ensure all staff members receive up-to-date training on regulatory requirements, clinical protocols, and best practices
• Ensure compliance with continuing education requirements for all transplant staff
• Oversee the implementation, maintenance, and optimization of transplant information systems
• Ensure that IS solutions meet regulatory requirements and support efficient clinical workflows
• Develop and maintain data management systems for accurate reporting and analysis
• Stay informed about emerging technologies in transplant care and evaluate their potential implementation

• Manage quality and compliance staff, staff educator, and transplant IS team within the transplant program
• Collaborate closely with transplant administrators, clinical directors, and organ-specific teams
• Participate in strategic planning for the transplant program
• Represent the transplant center in regional and national quality forums
• Foster a culture of continuous learning and improvement across all teams under supervision
• Provide leadership and mentorship to quality and compliance team members
• Collaborate with multidisciplinary teams, including surgeons, physicians, nurses, and administrators
• Participate in strategic planning for the transplant program
• Present quality and compliance reports to senior leadership and relevant committees

• A Master's degree in a relevant field of study and seven or more years of relevant experience; with at least 4 years in a leadership role .
• Registered Nurse in the State of California upon hire.
• Demonstrated experience in quality improvement, regulatory compliance, operational efficiency, staff education, and information systems management in a transplant setting.
• Demonstrated knowledge of organ transplant CMS Conditions of Participation and UNOS/OPTN policies, Title 22, and hospital Joint Commission requirements.
• In-depth understanding of solid organ transplantation processes, regulations, and information systems.
• Proficiency in quality improvement methodologies (e.g., Lean, Six Sigma).
• Strong analytical skills with experience in data analysis and performance monitoring.
• Excellent project management and change management skills.
• Proficiency in electronic medical records systems and data reporting tools.
• Understanding of adult learning principles and educational program development.
• Knowledge of current trends in healthcare information technology, particularly in transplant care.

• Master's degree in Nursing
• Certified in healthcare quality (CPHQ), Lean Six Sigma Black Belt (LSSBB) or similar certification.
• Certified Clinical Transplant Coordinator.
• Experience in Epic/ Phoenix transplant EMR module.

• Employment is subject to a criminal background check and pre-employment physical.
• Must be able to work various hours and locations based on business needs.