Job Ref: 28102
Talent Area: Laboratory
Houston Methodist Sugar Land Hospital
Sugar Land, TX 77479
Employment Type: Regular
Job Type: Full-Time
Organization: Houston Methodist
Work Shift: DAY
Work Week: M - F
Since 1998, Houston Methodist Sugar Land Hospital has been serving Fort Bend and the surrounding counties. Residents have come to rely on a level of compassionate care and leading-edge technology that was once available only in the Texas Medical Center. With 243 licensed beds, 20 operating rooms and over 1,900 employees, Houston Methodist Sugar Land Hospital was designed to provide comprehensive, personalized care for the community.
SUMMARY: Develops, maintains, and monitors the quality management system for Laboratory Services. Documents all significant activities and directs process improvement activities as necessary. Ensures compliance with all federal, state, local, The Joint Commission, CAP and hospital policies and procedures. Manages CAP external proficiency program as well as internal Critical Incident program. Coordinates reports for the department and performs activities that ensure that the laboratory and point of care testing sites comply with regulatory agency requirements (TJC, CLIA, and CAP).
DUTIES AND RESPONSIBILITIES: 1. Assist with the development and the implementation of the Quality Assurance program for the laboratory and performs annual assessment. 2. Reviews all laboratory quality occurrence data; provide reports and graphical data to department management, clients and customers. 3. Serves as document control officer for Laboratory Services procedures to ensure annual review and sign-off of all policies. 4. Prepares quality reports to include specific monitors as defined by the Manager/Director. 5. Manages laboratory external proficiency testing program and tracks exceptions ordering, distributing proficiency testing samples to sections, routing results for review, monitoring results and initiating corrective action. 6. Coordinate activities associated with point-of-care (POC) testing program throughout the hospital to include evaluation of equipment, policy development and implementation/monitoring of quality control. 7. Prepare, implement, and initiate review of laboratory policy and procedures, performing literature searches as needed to ensure regulatory agency requirements are addressed and met. 8. Coordinate activities associated with the preparation for CAP inspection, coordinate follow-up for any deficiencies, assist with the everyday readiness for The Joint Commission (TJC) unannounced inspections. 9. Coordinate department activities necessary to meet all accreditation and governmental agency standards (TJC, CAP, and CLIA) hospital policies and procedures. 10. Responsible for formal presentations for committee meetings and educational programs and informal presentations to direct meetings and discussions with coordinators and staff in developing strategy and action plans for programs/projects. 11. Analyzes and responds to client complaints, unusual incident reports and Risk Management inquires. 12. Coordinates the validation and implementation of new testing and instrumentation. 13. Demonstrates the components of the I CARE values statement (Integrity, Compassion, Accountability, Respect, and Excellence). 14. Demonstrates Customer Service standards (smiles and makes eye contact; greets each patient and visitor; seeks out patient and visitor contact; displays appropriate body language at all times; takes 5 minutes each day to go above and beyond for one patient or visitor; honors diversity; thanks every customer). 15. Follows all safety rules while on the job. Reports all accidents promptly and corrects minor safety hazards. Communicates with peers and management regarding any hazards identified in the workplace. Rounds frequently to assess for safety and compliance, patient, and physician satisfaction. 16. Performs other duties as assigned, which include assisting with staffing needs across the service line as competencies allow.
EDUCATION REQUIREMENTS: Bachelor degree in related field required.
EXPERIENCE REQUIREMENTS: Must have a minimum of 3 years of related experience.
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED: Must meet the eligibility requirements and/or be certified by the Board of Registry (American Society for Clinical Pathology (ASCP), National Certification Agency (NCA) or a discipline specific registry).
Houston Methodist is an Equal Opportunity Employer.
Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.
VEVRAA Federal Contractor – priority referral Protected Veterans requested.