Job Description

Cabell Huntington Hospital

is seeking a

full-time Lab Quality Assurance Coordinator

.


. Functions as a member of the Cabell Huntington Hospital (CHH) Laboratory Services Team. Plays a central role in the quality assurance, performance improvement program, and the training of laboratory personnel.


. Manages the QA/PI program for the purposes of monitoring and evaluating the quality and appropriateness of patient care services provided by CHH. Helps develop annual performance improvement initiatives and action plans. Submits an annual assessment of the QA/PI program to the Medical Director and Laboratory Manager.


. Evaluates the quality of services and adequacy of equipment, personnel, and working accommodations through on-site inspections and/or review of reports in various areas of the laboratory department. Writes and presents summaries, reports, charts, and graphic representations on topics concerning laboratory services and quality assurance. Analyzes current and historical data for trends.


. Plans and conducts studies on technical and administrative problems involving personnel, organizational structure, new technology, program deficiencies, reporting systems, etc.; recommends changes based on findings.


. Interprets agency policies and directives, prepares guidelines governing laboratory operations, and advises supervisors on preparation, maintenance, review, and revision of procedure manuals. Plans for and implements laboratory improvement programs. Writes Standard Operating Procedures (SOP) and instructions relevant to a comprehensive QA/PI program.


. Determines training objectives and develops curriculum and materials to accomplish objectives. Creates original materials for quality control training. Uses expertise to select those techniques that represent the most current and effective laboratory processes.


. Assists with the establishment professional standards that comply with accreditation requirements and regulatory procedures including Joint Commission, CAP, AABB, OSHA, CLSI, and CLIA. Develops criteria consistent with accreditation requirements. Independently determines requirements for specialized laboratory techniques and establishes effective criteria. Ensures criteria represent acceptable standards of quality and can be measured, controlled, collected, evaluated, etc. in an efficient manner. Directly communicates with regulatory agencies including CAP, AABB, CLIA, & JC. Standardizes Quality Assurance & Performance Improvement activities throughout the Medical Center and Ironton campus.


. Assures compliance with proficiency testing programs. Plans, implements, and coordinates acceptable proficiency testing programs in all areas of laboratory medicine. Advises the Medical Director, Laboratory Manager, Supervisors on annual survey selection and coordinates the ordering of surveys with procuring authority. Reviews, evaluates, and monitors the proficiency testing programs to ensure the adequacy of test methods, equipment, process, and competency of personnel performing proficiency testing. Ensures investigation of all failed survey results or results with an identified CAP code and documentation of corrective actions throughout all of CHH, including Point-of-Care Testing sites and outreach facilities.


. Oversees a comprehensive training and competency assessment program for all laboratory medicine personnel; identifies training needs, arranges for/personally conducts in-service training in Current Good Manufacturing Practices, evaluates the effectiveness of training programs and recommends improvements to the program as appropriate.


. Maintains current professional advances through formal education and professional training and networking. Ensures the adequacy of the scientific knowledge applied in the performance of required tests. Recommends the addition or deletion of new tests to the laboratory's service. Evaluates new techniques or practices and determines the feasibility of implementing at CHH Laboratory or at outreach facilities.


. Establishes and maintains liaison with other Federal and state agencies, accrediting organizations, academic institutions, and commercial and private laboratory facilities to keep abreast of new developments, obtain services, and develop and coordinate mutually beneficial projects.


. Develops instructions for converting from manual to automated testing systems. Obtains the necessary approval to implement new techniques or practices at CHH Laboratory or at outreach facilities. Prepares professional implementation plans, including test and evaluation of the techniques in meeting stated objectives. Standardizes Standard Operating Procedures (SOP's) throughout CHH and outreach facilities.


. Utilizes the cloud-based software suite for maintenance and upkeep of document control, inspection readiness module and compliance/continuing education requirements.


. Recognizes and defines testing problems and evaluates methods for solution. Evaluates guides or implements possible alternative approaches to standard methods. Ensures the quality of laboratory services and adequacy of equipment, personnel, and working accommodations through on-site inspections and/or review of reports. Assess laboratory needs and explore sources and methods of obtaining necessary resources. Ensures compliance with quality control and proficiency testing programs, safety standards, accreditation requirements, and agency policies. Plans for and implements laboratory improvement programs. Participates as an essential inspection team member for peer review of outside laboratories.


. Establishes record keeping systems to assure the accuracy and validity of test results. Facilitates preparation of medical documentation that meets professional standards and accreditation agency requirements. Plans, implements, coordinates, and reviews record keeping methods and programs.


. Protects patient confidentiality by following the Hospital's Ethics-Confidentiality and Privileged Information Act (HIPAA). . Follows established CHH and laboratory guidelines for personal phone use. . Participates in training students and new employees following the guidelines of the laboratory.


. Recognizes and performs duties which need to be performed although not directly assigned; regularly helps others. . Completes assigned duties in a timely manner, allowing time to assist with other members and/or other assigned or non-assigned duties.


. Takes advantage of opportunities presented in gaining knowledge that foster development or acceptance of new ideas and concepts. . Performs other duties as assigned. . Strong communication skills, customer service oriented. BLS certification is required and must be maintained during employment.


. The position requires a professional knowledge of medical technology applicable to a wide range of duties in one or more specialty areas or functions, and a high level of skill in applying this knowledge in solving very complex problems involving diverse aspects of clinical laboratory practice; modifying or adapting established methods and procedures or making significant departures from previous approaches to solve similar problems; revising standard methods to improve or extend test systems; and evaluating, modifying, or adapting new methods to meet the requirements of particular testing situations.


. Knowledge of regulatory, licensing, and accrediting agency requirements, and statutes governing clinical laboratory operations sufficient to use in planning, implementing, or monitoring laboratory programs/ services (e.g., determining needs, assuring compliance with standards).



. Knowledge to coordinate the laboratory wide CAP proficiency testing program and perform referencing for CAP survey programs. . Knowledge of management, administrative, and coordinative skill sufficient to effectively provide advisory, review, inspection, education and training, and problem-solving services (e.g., troubleshooter, specialist, and coordinator) in the areas of quality control, quality assurance and process improvement projects and programs.


. Knowledge and skill in making qualitative evaluations of laboratory services, developing/revising guidelines, and standards for use by operating personnel, and incorporating new technology in laboratory programs. Ability to establish laboratory wide protocols for new testing methods, new reference ranges, and new validation techniques.


. Knowledge of mathematics and statistics as related to laboratory medicine practices including quality assurance and systems and process analysis. . Knowledge of the types of surveillance needed to monitor variables that affect the quality of services, and skill in evaluating and interpreting results of quality control procedures, quality assurance data collection, and implementing corrective action where indicated.


. Knowledge of current instrumentation used in clinical laboratories and skill in the operation, calibration, maintenance,



and troubleshooting of equipment used.


. Practical knowledge of computer operations to ensure proper control of patient specimens and standard software programs used to collect, collate, analyze, and present data.


. Knowledge of the chain-of-command as it applies to this specific position, and judgment and skill to determine the proper point within that chain of command to initially address various issues related to quality assurance. . The incumbent must have an outstanding knowledge of the Laboratory Safety Program and must demonstrate continual compliance with the program.


Requirements:
Education:


High School diploma or equivalent is required Bachelor's degree is required American Society of Clinical Pathology (ASCP) or American Medical Technologists (AMT) is required West Virginia State Licensure Clinical Laboratory Scientist is required
Experience:


Minimum of 2 to 5 Years of Position-Related Experience is required 5+ Years of Position-Related Experience is preferred

The kind of position-related experience includes: Minimum five years of laboratory experience required, to include clinical (including blood bank) and anatomic pathology. Background in quality assurance activities is highly desired and preferred.