Implements and coordinates an ongoing Quality Management & Safety Programs pertaining to Quality Control, Quality Assurance, Quality Improvement, Document Control, Quality Process Engineering, Regulatory Compliance (CAP, AABB, Joint Commission, CAHO, and CLIA standards), Lab Safety and Patient Safety.
Conducts Quality planning and ensures that quality assurance criteria and quality control requirements are consistent with CAP, AABB, Joint Commission, CLIA, and other applicable accreditation/regulatory agencies. Modifies the program and/or its components.
Leads the Department of Pathology's Quality Council. Ensures that quality measures for each section have been identified and are reported and communicated. Collects and monitors key quality measures for departmental and institutional reporting. Identifies areas for quality improvement efforts. In conjunction with the Pathology Quality Council heads the departmental quality planning activities by meeting. Assists lab sections with a plan to meet those objectives.
Participates in the D-H Patient Safety Forum. Acts as the departmental liaison with the D-H Quality and Patient Safety Office. Participates on interdisciplinary performance improvement teams to improve quality. Assists in the identification and improvement of processes/systems that may compromise patient safety.
Assists lab sections with the preparation for regulatory inspections by conducting audits, mock inspections and checklist review sessions. Ensures each section's Proficiency Testing program is complete based on test activity menu. Ensures CAP survey or other PT material is reported in a timely manner. Ensures Proficiency Testing documentation is complete and retained for appropriate period of time.
Ensures that departmental policies and procedures are up-to-date and consistent with existing institutional policies and promote compliance with CAP, AABB, Joint Commission, CLIA, and other applicable accreditation/regulatory agencies. Coordinates standardization of documents (e.g. policies, procedures, forms) throughout the department. Works with section supervisors and the Laboratory Information System (LIS) Team to educate and train staff on the use of the Pathology Document Control System.
Assists with the monthly collection of Scorecard data. Reviews at least monthly with others results of the Pathology Scorecard and Departmental Quality Performance measures.
Supervises the Laboratory Safety and Compliance Coordinator. Assigns, directs and oversees responsibilities to this role to ensure that all state and accreditation requirements are met.
Reviews safety occurrences and actions taken. Assigns follow-up review. Ensures that incidents have been appropriately investigated. Evaluates incident reports and report to Pathology Quality Council. Works together with appropriate personnel to improve systems to avoid recurrence.
Facilitates departmental performance improvement teams and provides training in Process Engineering improvement tools (LEAN, Six Sigma, PDCA, Microsystems, etc.) when indicated.
Acts as Departmental Education liaison with University of New Hampshire, River Valley Community College and other schools to ensure contractual student education requirements are met.
Ensures all Pathology staff receives training and education in regards to organizational patient safety priorities and quality improvement practices.
Performs other duties as required or assigned.
Bachelor's in a clinical laboratory related field with 8 years of laboratory experience (to include previous supervisory or lead experience) or equivalent required.
Demonstrated experience with coordinating/managing quality, performance improvement, and/or accreditation required.
Previous experience using LIS, spreadsheet and database software desired.
Must be self-directed and have excellent communication and interpersonal skills. Excellent organizational, project management, communication and leadership skills required.