Quality and Compliance Manager - Lab - Waterbury Hospital

Waterbury, CT 06702

About the Job

SCOPE OF POSITION:

The position is responsible for the overall quality and compliance requirements of laboratory services at Waterbury Hospital inclusive of outpatient locations. Specific aspects of quality are associated with The Joint Commission, The College of American Pathologist’s Quality Management System, Proficiency Testing, Quality Control, Process Improvement Inspection Readiness and metric reporting on measurements such as turnaround time. The position also is the key individual associated with the annual Connecticut DPH renewal.

RESPONSIBILITIES:

Key Accountabilities:

Ensures that all reported analytes are covered by a proficiency testing challenge. In collaboration with Team Leads, organizes the yearly purchase and cross references the test menu with proficiency testing. Ensure that staff rotate challenges and that all challenges are submitted within time expectations. In coordination with the Medical Director and Administrative Director ensure that all challenges and unexpected results are properly investigated and documented.

Ensures a state of inspection readiness with The College of American Pathologists through periodic and active preparation. This includes mock inspections, regular review of CAP requirements, regular updates to resource checklists and specific focused efforts on areas of previously cited deficiencies. Develops an annual plan to ensure readiness and regularly reports to the Medical Director, Administrative Director and Team Leaders. Acts as the point person to organize the hospital for the inspection window.

In collaboration with Team Leaders, ensures that all quality control is performed, monitored and that the appropriate level of intervention occurs with unexpected or discrepant results.

In collaboration with the Medical Director, Administrative Director and Team Leaders, develops an annual list of metrics associated with Process Improvement. Collates and reports data to the appropriate entities. Ensures that the efforts result in quantifiable improvements.

In collaboration with the Medical Director and Administrative Director, ensure that the annual renewal of the Connecticut DPH application occurs. Gathers and stores a compendium of expected data. Develops a cycle to pull such automated data as might be required. The application should start on November 15 or each year and conclude with submission prior to December 31.

Ensures compliance with such agencies as OSHA with regards to the chemical compliance plan.

EDUCATION/CERTIFICATION

Bachelor of Science Degree in sciences
MT/CLS or through ASCP or equivalent

EXPERIENCE

Not less than three (3) years active work in a clinical laboratory.

Not less than one ( 1) year evidence of progressive authority.

COMPETENCIES:

Develops strong trusting relationships in order to gain support and achieve results.
Organizational thinking and strategic ability to consult with leaders.
Critical thinking/problem solving and ability to be self-directed and implement decisions.
Task-driven, results-oriented. • Functional literacy with Office Suite, Laboratory Information Systems and websites such as CAP
Perform automated functions that fall within job responsibility.
Ability to adapt in a dynamic environment. • Ability to interact with internal as well as external customers with tact and confidentiality.
Ability to utilize Technical and Human Resources.
Excellent verbal and written communication skills.
Evidence of continual learning

Job Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job. They are intended to be accurate reflections of the principal duties and responsibilities of this position. These responsibilities and competencies listed above may change from time to time.

Waterbury Health considers applicants for employment without regard to, and does not discriminate on the basis of an individual’s sex, race, color, religion, age, disability, status as a veteran, or national or ethnic origin; nor does Waterbury Health discriminate on the basis of sexual orientation or gender identity or expression.

PI241539112

Source : Waterbury Hospital