To serve as a facilitator of quality assessment activities for Laboratory Services to include patient safety initiatives, regulatory and accreditation compliance, risk management, laboratory safety, and performance improvement in all clinical and anatomic pathology laboratory departments. Works with laboratory divisions to develop plans and policies for improved quality throughout the department, and works with top management and leadership to ensure compliance with regulatory agencies. Coordinates reporting for Laboratory Services quality management and improvement programs. Ensures compliance with the Hospital Performance Improvement Plan, Quality Improvement Plans, Joint Commission Accreditation Standards, College of American Pathologists (CAP), Centers for Medicare and Medicaid Services (CMS), Clinical Laboratory Improvement Amendment (CLIA) requirements, and other accrediting agency requirements. Relies on extensive experience, judgment and self-initiative to plan and accomplish goals.
- Organizes quality management activities for the department of Laboratory Services, including laboratory divisions.
- Coordinates the identification, monitoring, resolution, and follow-up of patient care and departmental projects, goals, and operational issues.
- Identifies appropriate internal controls for department to facilitate compliance; provides mechanisms to monitor and enforce compliance.
- Oversees and manages document control process for departmental policies and procedures to ensure compliance with annual review requirements.
- Participates in the monitoring, reporting, and improvement activities related to clinical guidelines, healthcare quality/safety initiatives, accreditation and regulatory requirements, in collaboration with clinical staff and leadership.
- Provides guidance in the analysis of departmental activities related to HIPAA compliance and other compliance related matters.
- Monitors and advises on the performance of the quality management system, and produces data and report on performance, measuring against set indicators.
- Acts as a liaison with management and staff throughout the department to ensure that the QA system is functioning properly.
- Organizes, attends and facilitates departmental quality management meetings. Uses data to assist departments in making process changes.
- Educates and assists clinical labs in developing appropriate ongoing quality management/monitoring programs.
- Ensures compliance of areas of responsibility with CMS, Joint Commission, CAP and other accrediting agency requirements. Acts as coordinator for CAP accreditation inspections.
- Assists in the development, interpretation, and implementation of departmental policies including lab safety procedures.
- Facilitates departmental Quality Management Committee meetings and divisional lab quality meetings.
- Facilitates departmental Laboratory Safety Committee meetings.
- Adheres to internal controls and reporting structure.
- Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of developmental needs that contribute to the enhancement of patient care.
- Communicates PI and quality/safety activities to leadership and QM staff.
- Performs related duties as required.
Equal Employment Opportunity
UTMB Health strives to provide equal opportunity employment without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or veteran status. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.