Job Abstract

In collaboration with Director, develop, implement and evaluate the quality management program for the Division of Laboratory Medicine, including processes and monitors. Manage the departmental occurrence reporting processes, including capturing, categorizing and analyze the data to determine opportunities for process improvement. Serve as project manager for departmental or interdepartmental projects, including LEAN. Develop and maintain QA/ PI data collection systems and database, and write bi... more detailsweekly reports for the Laboratory Quality Assurance Committee. Manage the Laboratory Quality Assurance Committee activities. Facilitate laboratory quality improvement activities resulting from review of occurrence data. Develop and maintain appropriate quality policies and procedures to ensure consistent practice. Report on quality improvement activities to senior leadership. Develop and oversee the process for managing variances, including performing or assisting in ACA and RCA, and implementation of action plans. Serve as a resource for Technical Directors and Managers in collection of process variance data, analysis of data and implementation of improvements indicated. Develop and maintain a document control program for the department. Participate in departmental administrative functions such as development and implementation of goals and policies and procedures. Serve as the laboratory safety officer, maintaining the laboratory safety manual and monitoring for compliance within the laboratory and coordinate policies related to safety with hospital safety officer. Responsible for the Laboratory Safety and Chemical Hygiene Plans. Develop and lead the accreditation/regulatory readiness program to continually assess current performance with The Joint Commission, CAP, DC DOH, FDA, AABB, FACT, and CLSI requirements; facilitate creation of corrective action plans and implement as needed. Maintain current knowledge of accreditation and regulatory requirements. Coordinate departmental preparation for accreditation and regulatory surveys and self-inspections. Complete applications, coordinate any payments, and ensure all required documents and organizational or departmental changes are appropriately relayed to agencies and accrediting bodies in a timely manner. Coordinate and facilitate all activities during laboratory surveys. Coordinate post-survey communication and development and submission of corrective action plans. Coordinate subscription to proficiency testing. Develop and maintain process for monitoring proficiency testing results and ensure responses to unacceptable results meet regulatory guidelines. Speak up when team members appear to exhibit unsafe behavior or performance Continuously validate and verify information needed for decision making or documentation Stop in the face of uncertainty and takes time to resolve the situation Demonstrate accurate, clear and timely verbal and written communication Actively promote safety for patients, families, visitors and co-workers Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance CN Hospital (Main Campus) (L 002) 111 Michigan Avenue Washington 20010