Ensures that Laboratory testing systems developed and used for each test performed provide quality services for all aspects of test performance phases of testing (pre-analytical, analytical and post-analytical); establishes and maintains acceptable levels of analytical performance for each test system; evaluates testing volumes, new test systems and equipment and maintains or exceeds standard of care through selection of testing to bring on-site, new systems and/or replacement or addition of equipment.
Ensures that the physical plant and environmental conditions are appropriate for testing performed in the laboratory, prevention of the transmission of infection in the facility and provision of a safe working environment for employees and staff working within the facility.
Ensure that methodologies selected are evidence based and capable of providing quality results to meet or exceed the standard for patient care; verify that procedures used are adequate to determine accuracy, precision or other pertinent performance characteristics of the method; test methods or procedures are developed, performed as required for accurate and reliable test results and/or optimum patient care outcome; initiates audit or monitoring activities as needed to identify and reduce.
Ensure that the laboratory is enrolled in a CLIA/CMS approved proficiency testing program for the testing performed; proficiency testing samples are tested as required and results are returned within the accepted time frame; results of proficiency testing is reviewed by staff, evaluated for laboratory performance and any problems that require corrective action are identified; an approved correction plan is followed when any proficiency testing result is found to be unacceptable or unsatisfactory.
Ensures that quality control and performance improvement programs are established and maintained to assure the quality of laboratory services provided and to identify failures as they occur; all necessary remedial actions are taken and documented whenever significant deviations from the laboratory established performance characteristics thresholds are exceeded, and that patient test results are released or patient care procedures performed only when the system is functioning properly.
Ensures sufficient number of skilled staff with the education, training and/or experience to provide appropriate consultation, properly supervise and accurately perform tests and report test results in accordance with applicable personnel standards; acts as proctor for various schools in the placement of phlebotomy student externs; & MLT student externs competency testing is performed and monitored with remedial training provided as necessary or disciplinary action taken per protocol; specifies in writing the responsibilities and duties of each laboratory employee, as well as each person engaged in the performance of testing and patient care that identifies which examinations, procedure, each individual is authorized to perform, whether supervision is required or whether supervisor review is required before reporting patient test results or performance of a patient care procedure.
Ensures that policies and procedures are established for orientation and monitoring individuals or processes involved with the conduction of analytical test phases, emergency preparedness; identification of remedial training or continuing education; assist in approval of procedures and equipment related to surveillance prevention, assure that respective manuals are reviewed and available to all personnel.
Establishes and maintains educational opportunities for hospital staff regarding emergency preparedness related to identification and management of biohazards/outbreaks/biological events, surveillance, assists emergency preparedness coordinator in reviewing and development of policies and procedures to ensure preparedness of staff to natural or man-made disasters or emergencies; meets the requirements of accreditation and licensing agencies.
Performs other duties as assigned by the V.P. Patient Services.
Baccalaureate degree from an accredited college/university in Clinical Laboratory Medicine. Registry with a recognized board of registry (ASCP or equivalent agency) required.Minimum of five years of major hospital laboratory supervisory experience. Must meet CAP Gen 53625 Technical Consultant.
Assumes responsibility for planning, coordinating and directing all the functions of the Laboratory, consistent with regulatory requirements and needs of the organization; including but not limited to staffing, training, scheduling, development and maintenance of departmental budgeting, ordering of supplies and determination of capital needs and offering of services. Ensures establishment and quality monitoring of appropriate laboratory standards for service. Develops, monitors, and takes corrective action with regard to productivity and budgetary standards for service. Assumes responsibility for ensuring compliance with all policies, procedures, regulations and requirements of Eaton Rapids Medical Center, The College of American Pathologists, DNV, and other regulatory agencies. Supports and follows hospital safety and health rules, personally intervenes in the leadership, behavior and training of staff in regards to safety and health policies and practices. Reviews specific safety and health expectations for and with departmental staff. Evaluation will reflect accountability for the performance of these safety and health expectations.
Job ID: 296009544