Laboratory Quality and Compliance Manager

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About the Role

Under minimal supervision, reports to the Laboratory Administrative Director and the Laboratory Director of Services. The Laboratory Quality and Compliance Manager is responsible for establishing, maintaining, and monitoring a centralized quality improvement program for the Denver Health laboratory, ACS laboratories, School Based clinic laboratories, Public Health laboratories, Point of Care testing, and any and all other clinical laboratories affiliated with Denver Health. Ensures continuing conformance with all legal and accrediting agencies required for the laboratory. Serves as the liaison to other services across the Denver Health enterprise as a consultant, mentor, and teacher coordinating laboratory standards and compliance.

Responsibilities

• Establishes an effective presence in the laboratory and patient care units to promote open communication between employees, supervisors, and those the laboratory serves. (15%)
• Plans, organizes, and administers a performance improvement program for the laboratories that meets criteria for ongoing actions for improved patient and testing outcomes. (5%)
• Develops and implements an annual performance improvement plan for the laboratory. (5%)
• Submits laboratory quality reports to the hospital quality program in a timely manner and as needed to provide support to quality activities, represent patient advocacy through laboratory quality, and encourage changes for better outcomes. (5%)
• Organizes and administers the Laboratory QI Committee, which serves as an educational tool to laboratory staff through the review of specific patient events or current laboratory processes/workflows. (5%)
• Tracks changes, accomplishments, and activities of the committee. (5%)
• Monitors individual department projects, laboratory projects, and mentors for use of tools, quality outcomes, and individual and departmental growth. (5%)
• Participates in interdepartmental committees and lean activities to promote performance improvements and process changes. (5%)
• Initiates formal/informal activities with employees regarding departmental cohesion and collegiality for quality processes and outcomes. (5%)
• Assigns and completes investigations as needed with safety incidents and, when required, participates with other departments in process change activities (e.g., Quality Process Improvement (QPI), Medical Quality Improvement Conference (MQIC)). (5%)
• Conducts special studies at the request of management to provide facts, numeric outcomes to study complex issues for improvements, audits, and/or surveys. (5%)
• Researches compliance regulations to ensure laboratory compliance and predict changes required by developing standards. (5%)
• Distributes compliance requirements to all supervisory staff and confers with them to determine the extent of compliance. (5%)
• Educates, mentors, and prepares all departments performing testing for regulatory compliance and standard interpretation. (5%)
• Acts as a liaison and consultant resource for intra- and interdepartmental compliance questions and/or issues. (5%)
• Works with the regulatory compliance staff and assists in developing a compliance plan for the laboratories. Educates employees on compliance regulations and assures conformance with these regulations. (5%)
• Monitors the laboratories' proficiency testing programs to ensure timeliness of reporting, action plans for improvement when there are failures, and appropriate testing challenges across all entities performing patient testing. (5%)
• Completes the Joint Commission “Focused Standard Assessments” when assigned in conjunction with the department staff and provides documented action plans for regulatory compliance. (5%)
• Participates in tracers, mock surveys, and survey activities to maintain compliance with accrediting agencies. (5%)

Requirements

• Bachelor's Degree (Required)
• Four years of laboratory experience (Required)
• MLS/ASCP-Medical Laboratory Scientist certification from the American Society for Clinical Pathology (Required)

Skills

• Knowledge of accreditation standards for the Joint Commission, American Association of Blood Banks, FDA, CMS, CLIA, and other regulatory agencies.
• Knowledge of inspections or surveys and the ability to implement corrective actions.
• Knowledge of environment of safety issues.
• Ability to write, review, and update policies and procedures and improvement plans.
• Excellent communication and customer relation skills to ensure patient safety and quality processes in the laboratory.
• Ability to perpetuate teamwork.
• Ability to display visuals and speak to all quality improvements both inside and outside of the laboratory.
• Ability to coordinate, plan, or participate in quality assessments for improvements.

Pay

$86,300.00 - $133,800.00 / year

Benefits

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, and vision plans in addition to employer-paid disability and life insurance
• Comprehensive well-being programs including on-site employee fitness center and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) supporting internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer with free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHSC) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation. It includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan, and Denver Health Foundation. As Colorado’s primary and essential safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many cultural and recreational activities.