This position manages all aspects of the clinical laboratory quality assurance (QA) program. The position ensures the ongoing compliance with lab regulatory agencies (FDA, AABB, CAP/CLIA, and JCAHO) through the establishment of a system-wide lab quality management program. Ensures that monthly lab-wide quality reports are developed to establish/maintain focus on delivering a mature quality culture. The position oversees quality coordinators to ensure the following tasks are completed. Initiates, monitors and analyzes trends in Laboratory performance to test performance, turnaround time, customer service and other established lab KPI system and process audits. Position serves as lab liaison to PCH’s internal quality and patient safety committees.

• Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
• Excellence in clinical care, service and communication
• Collaborative within our institution and with others who share our mission and goals
• Leadership that set the standard for pediatric health care today and innovations of the future
• Accountability to our patients, community and each other for providing the best in the most cost-effective way.

1. Effectively Manages Laboratory Quality Management activities.
   • a. Customizes the Laboratory’s quality improvement and safety/hygiene reports on a regular basis so the information relayed will be pertinent and timely to each audience reviewing the data.
   • b. Develops and implements solutions to improve services and creates methods to quantify these levels of improvement to demonstrate the potential level of quality achieved.
   • c. Recognizes, monitors, and analyzes trends in Laboratory activities for the purposes of improving process flow, enhancing productivity, and/or increasing patient and employee satisfaction.
   • d. Assists in developing and writing Laboratory policies and procedures, as pertinent to job duties.
   • e. Serves as a liaison between Laboratory and other hospital areas to coordinate all quality improvement activities for optimal efficiency and effectiveness; recommends process changes as appropriate.
   • f. Uses effective process improvement techniques to identify outliers in all processes of Laboratory services, to include communications, order entry, specimen collection, processing and testing, and results reporting and billing.
2. Manages the Laboratory Safety and Chemical Hygiene Plans.
   • Maintains a safe environment for Laboratory staff and comply with governmental and institutional regulatory policies.
3. Partners with Laboratory Information System Analyst(s) with changes, modifications, and enhancements to the Laboratory Information System.
   • a. Provides guidance to the IT team to initiate and test related quality improvement enhancements.
   • b. Ensures that lab test dictionaries are maintained in an accurate and current format.
   • c. Ensures that lab billing practices meet or exceed regulatory and commercial payer standards.
4. Manages programmatic implementation of accreditation standards.
   • Provides oversight for inspection activities. Serves as liaison for activities involving regulatory (i.e., government) bodies and internal patient safety committees, root cause analyses.
5. Oversees system and process audits of a multi-site lab network.
   • To ensure consistency of technical performance and regulatory compliance.
6. Performs miscellaneous job related duties as requested.