MedStar Georgetown University Hospital, a 609-bed academic hospital, is one of the nation's leading teaching and research hospitals.

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MedStar Georgetown University Hospital has been ranked by U.S. News & World Report as a "high performing" hospital for cancer, diabetes and endocrinology, geriatrics, gynecology, nephrology, neurology and neurosurgery, orthopedics, pulmonology and urology.

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.

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Director, Quality Improvement, Regulatory Affairs and Education
Category: Nursing Leadership
Job Requisition: 13083
Department: Transplant - Administration & Post-Surgery
Facility: MedStar Georgetown University Hospital
Geographic Region: Washington, DC
Schedule: Full Time
Shift: Day Shift
Hours per Week: 40.00
Location: Washington, DC
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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 MedStar 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; conducting quality of patient care audits of transplant patients at MedStar Georgetown University Hospital and MedStar Washington Hospital Center; participating in the development of information on clinical transplantation topics for education of clinical staff in the MedStar 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 ensuring compliance with all data management and reporting requirements as set by CMS, Joint Commission, UNOS, and 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 healthcare-related or management curriculum. 
  • LICENSURE AND/OR CERTIFICAION: RN preferred. If a registered nurse, must be a graduate of an accredited school of nursing and hold a current D.C. 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 and clinical skills. Ability 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). Collaborates with inpatient, perio-op and quality department team members who 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 to 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 addressing 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 and plans of correction in a timely manner.
  • Conducts internal audits of the quality of care provided by attending physicians, fellows, residents, and mid-level providers for a variety of disease states. 
  • Analyzes quality, safety and outcomes data to identify trends. 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 MedStar 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 D.C. 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.
  • Participates 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 are 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.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations.

A qualified individual with a disability will be considered for employment on the same basis as non- disabled applicants if he/she can perform the essential functions of the job sought, with or without a reasonable accommodation, and without imposing a direct threat to the health or safety of others or him/herself.

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