PURPOSE OF POSITION:
The Metropolitan Hospital Laboratory Quality Director, together with the Deputy Directors, Medical Director and Administrative Director, forms the leadership team for the Laboratory Department and is directly responsible for the overall Laboratory Quality Assurance and Performance Improvement Program.
AREAS OF RESPONSIBILITIES:
Quality assurance directors are tasked with defining and promoting a quality mindset across an entire lab and for complying with the Metropolitan mission statement. Directors are responsible for managing all QA functions, working with cross-departmental leadership to deliver high quality products on schedule. QA directors establish and maintain a quality system to ensure a company’s facilities, equipment, personnel, methods, processes, and procedures conform to both internal guidelines and regulatory standards: AABB, CAP, NYS DOH, FDA, CLIA, Joint Commission, EPA, HIPPA and OSHA.
SUMMARY OF DUTIES AND RESPONSIBILITIES:
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Design and implement Departmental Quality Improvement Monitors under the direct supervision of the Laboratory Director and participate in performance improvement activities.
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Prepare monthly reports detailing the results of all Quality Improvement initiatives.
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Monitor compliance of Quality Control documentation, corrective action and appropriate supervisory signatures in compliance with New York State and the College of American Pathologists recommendations and requirements
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Coordinates laboratory’s proficiency program with administrative director and monitors result submission, result review and corrective action for all P.T. failures.
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Assist the administrative director in maintaining a personnel competency program that includes technologists and supervisory personnel as per directives of the Clinical Laboratory Director.
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Follow all safety requirements and monitor safety compliance and processes in the Department.
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Coordinate yearly safety audits of entire department and follows up on corrective action for all deficiencies.
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Assess safety compliance in the laboratory and suggest ways to improve it.
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Make periodic revisions to Laboratory Safety Manual and Chemical Hygiene Plan.
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Evaluate new safety products and train laboratory staff in their use.
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Enforce laboratory safety practices with managers, supervisors and administrative director.
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Modify protocols and edit documents, with Director approval in order to improve laboratory workflow and processes.
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Interact with IT to ensure proper functioning and troubleshooting of LIS issues.
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May write procedures and/or prepare manuals as required.
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Represents the laboratory on the hospital’s Environment of Care Committee.
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Coordinates SDS yearly update and fire drill training.
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Ensure the laboratory has proper policies and procedures to comply with the New York State and the College of American Pathologists requirements.
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Coordinate CAP, NY State and JC applications and inspections with administrative director.
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Support other supervisory and managerial staff with regulatory agency preparedness.
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Participate in scheduled in-service training and educational programs to improve skills and expand the knowledge of the technical staff.
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Help to set up continuing education opportunities for the staff.
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Keep up-to-date on safety and regulatory issues.
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Utilize learning resources of the hospital system for professional development.
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Assist with orientation of new employees.Perform other assignments as required by the clinical and administrative laboratory directors.
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Participates in competency assessment of departmental staff.
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Complaints/Grievance (Internal and External) will all be directed to the Quality Manager for documentation, evaluation, review, and presentation to the Chairman and Senior Administrative Director.
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Ability to create reports that involve CAPA
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Ability to work with the Hospital Quality Assurance department
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All other duties as requested.
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Overseeing training and competency of the staff.
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Develops and implements departmental operating policies and procedures in accordance with Metropolitan Hospital policies and procedures and requirements of regulatory agencies.