Job Information

AdventHealth OPO Tissue Bank Quality Systems Manager FT in Orlando, Florida



OPO/Tissue Bank Quality Systems Manager at AdventHealth Orlando

Location Address: 601 E. Rollins St., Orlando, FL 32801

Top Reasons to work at AdventHealth Orlando

  • Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando

  • serves as the major tertiary facility for much of the Southeast, the Caribbean and South America

  • AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country

  • We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year

Work Hours/Shift:

  • Full Time, Days

You Will Be Responsible For:

OurLegacy is designated by the Centers for Medicare and Medicaid Services (CMS) as the only organ procurement organization (OPO) in east central Florida and is accredited by the American Association of Tissue Banks (AATB) as a tissue recovery agency. OurLegacy’s scope of operations extends to each of the following hospitals within the AdventHealth Hospital system: Altamonte, Apopka, Celebration, Daytona Beach, Deland, East Orlando, Fish Memorial, Kissimmee, New Smyrna Beach, Orlando, Palm Coast, Waterman and Winter Park. Additionally, CMS has designated OurLegacy to provide organ and tissue donation services to all non-AdventHealth acute care and critical access hospitals and free-standing emergency rooms in the following counties: Brevard, Flagler, Indian River, Lake, Okeechobee, Orange, Osceola, Seminole, Sumter, and Volusia.

The Manager of Quality Systems (MQS) is responsible for OurLegacy’s comprehensive organ and tissue donation quality systems. The MQS is responsible for working with OurLegacy leadership to ensure quality standards efforts in all departments. Leads the quality team in maintaining a data-driven organization committed to the highest quality standards and a culture of performance improvement. Responsible for leading the OurLegacy team in successful completion of required State and Federal audits – including Organ Procurement and Transplantation Network (OPTN), Center for Medicare and Medicaid Services (CMS), American Association of Tissue Banks (AATB), etc.

The MQS is responsible for donation data collection, validation, analysis and reporting. The MQS also works with OurLegacy partners to develop, evaluate and improve quality systems aimed at improving donation and transplant outcomes in our Donor Service Area (DSA). The MQS ensures required data submissions are accurate and timely.

The MQS is responsible for ensuring that OurLegacy organ and tissue charts undergo a strict Quality Review process. Ensures all OurLegacy partner relationships are maintained according to industry standards.


What You Will Need:


  • Bachelor’s degree in Business Administration, Healthcare Administration, Quality Systems, Statistics, or related field.

  • Three years of experience working in a quality or performance improvement role

  • Minimum of one year of progressive management experience


  • Master’s degree in Business Administration, Healthcare Administration or Quality Systems.

  • Two years of Quality, MIS or Data Management experience

  • Two years of Organ Procurement Organization (OPO) or Tissue Bank Management experience

  • Two years of experience managing a healthcare database system


  • Detail oriented

  • Knowledge and ability to understand OurLegacy’s departmental goals

  • Ability to supervise the activities of staff to meet deadlines and resolve problems

  • Strong time management skills; ability to meet required deadlines under pressure

  • Strong data analysis and data interpretation skills; ability to analyze data and ensure data integrity

  • Database and report-writing skills; skilled in querying a database

  • Strong communication and interpersonal skills

  • Ability to establish priorities and function independently as well as with teams


  • Understanding of PDSA (Plan, Do, Study, Act) procedure and methodology

  • Knowledge of the OPO and Tissue Bank Procedures

  • Knowledge of OPO regulatory agencies


  • Supervises Quality Control Coordinator


Develops and oversees quality system for collecting, validating, analyzing and reporting donation and transplantation data for internal and external OurLegacy partners. Maintains 100% compliance with data submission deadlines set by State and Federal agencies. Oversees the quality and integrity of OurLegacy data as well as these regulatory data submissions.

  • Works with the Director to respond to State and Federal agencies regarding questions about donation and allocation systems. This includes (but is not limited to) responding to OPTN regarding variations in organ allocation or other questions.

  • Develops and analyzes statistical measures of activity, quality and regulatory compliance throughout the organization.

  • Oversees the implementation of an organizational Quality Management Plan which will include systems for process improvement, document control, complaint management, error/accident reporting, and corrective and preventative actions. Implements ongoing performance improvement (PDSAs) to improve the overall organizational quality and processes. Leads the processes to recognize statutory changes in regulatory policies related to OurLegacy and communicates those changes to OurLegacy Leadership. Validates that the changes have been appropriately operationalized.

  • Oversees OurLegacy’s successful completion of regulatory agency audits to ensure OurLegacy meets or exceeds the regulatory requirements.

  • Schedules, coordinates and leads regular Quality Assurance and Performance Improvement (QAPI) meetings to ensure that quality and performance improvement programs and initiatives are implemented, managed and maintained as necessary throughout the organization and according to OurLegacy’s standards.

  • Consults on the development and the improvement of policies and procedures for appropriate data collection and regulatory compliance throughout the organization.

  • Manages staff who maintain strict quality standards for organ and tissue donor chart completion and ensures that all charts are accurate and complete. Models and promotes a culture of accountability and integrity in service to internal and external customers. Assists staff in managing his/her daily activities and maximizing his/her performance.

  • Analyzes marketplace trends, internal trends and practices and identifies patterns for consideration to improve practices. Participates in the organization’s strategic planning process and assists in defining goals and objectives to measure OurLegacy’s activities, qualities, trends and improvements

  • Analyzes existing information systems for overall effectiveness and when necessary, develops new systems to improve productivity and quality. Prepares specifications and time/cost estimates for the development and maintenance of comprehensive medical records management system that will provide security, quality and integrity of donor medical records.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Translife

Organization: AdventHealth Orlando

Schedule: Full-time

Shift: 1 - Day

Travel: AdventHealth Orlando

Req ID: 21039657

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.