Pathology Quality Assurance Coordinator

Texas Children's Hospital has an opening for a Pathology Quality Assurance Coordinator position in The Woodlands, TX.  Duties Include:

1. Conducts Proficiency Testing Program 

1. Maintains a proficiency testing plan that includes: annual order of proficiency testing samples, a process for how surveys are handled, a schedule of the ship dates of the surveys and, shipping notifications, and assignment of surveys to staff. 
2. Ensures that results are submitted by the deadline. 
3. Reviews proficiency testing results and responds to unsatisfactory results. Ensures corrective action, including staff retraining, is implemented as needed based on the investigation findings. 
4. Generates quarterly Proficiency Testing reports. 

2. Administers the Quality Assurance programs. 

1. Reviews tech logs and completed worksheets daily, identifies reporting errors and ensures that quality controls were performed as needed. Corrects results as needed and provides feedback to technicians. 
2. Reviews Laboratory quality control logs monthly; identifies outliers and implements corrective actions; provides feedback as needed; creates and distributes monthly reports as applicable; documents all findings and corrective actions. 
3. Maintains QA calendar to ensure required QA actives are performed per policy. Reviews validation/calibration/QC reports as applicable. 
4. Reviews and analyzes the quality indicator scorecards monthly. Presents data at quality, operations, or hospital quality meetings as applicable. Ensures implementation of the associated action plans and monitors for effectiveness. 
5. Maintains quality assurance policies and procedures f. Attends meetings; participates on work teams for new process improvement initiatives or projects as needed. 

3. Facilitates Process Improvement (PI) Projects. 

1. Set monthly meetings with the lab team as applicable 
2. Assist with setting the agenda for the meeting; compile quality assurance data to be reviewed 
3. Ensure to follow the DMAI2C (define, measure, analyze, improve, innovate and control) process improvement methodology 
4. Ensures thorough meeting minutes are documented 
5. Facilitate other team member has the opportunity to contribute to the project 
6. Maintain project worksheet until the end of the project 
7. Gather data and create reports for analysis; obtain current state and future state reports 
8. Maintain performance improvement (PI) database and track performance 
9. Assists staff with preparing and delivering the presentation to leadership team. 
10. Coordinate implementation with process owners and managers 
11. Post results on the Balanced Scoreboard-Connect site

4. Maintains Laboratory Accreditation Processes 

1. Maintains CAP (College of American Pathologist) checklist spreadsheets to ensure compliance to CAP standards. Keeps abreast of regulatory requirements and develop plans to maintain compliance. 
2. Conducts Regulatory Readiness Process’; coordinate tracer audits, collate data and produce reports, recommend corrective actions and assist in the implementation, monitors outcomes to ensure regulatory compliance. 
3. Conducts CAP self-inspection process, documents deficiencies and ensures implementation of appropriate corrective actions. 
4. Provides support to on-site CAP inspectors. Assists with timely submission of response to cited deficiencies. 
5. Serves as a QA contact person for CAP. 
6. Conducts CLIA/CAP Certification 
7. Is engaged in other regulatory/accreditation processes as applicable (i.e. AABB, FDA, JC etc.) 
8. Works closely with the Laboratory Director and Leadership to ensure consistency in Laboratory policies and procedures. Coordinates the Laboratory Document Control System: provides user training and support, performs monthly back-ups, manages the department structures within the application, generates and reviews compliance reports as applicable. 
9. Coordinates the Laboratory competency assessment program 
10. Coordinates lab product recall notices and ensures timely completion of responses to recall alerts

5. Safety 

1. Maintain safety policy and procedures

Requirement