ProMedica is a mission-driven, not-for-profit health care organization headquartered in Toledo, Ohio. It serves communities across nine states and provides a range of services, including acute and ambulatory care, a dental plan, and academic business lines. ProMedica owns and operates 10 hospitals and has an affiliated interest in one additional hospital. The organization employs over 1,300 health care providers through ProMedica Physicians and has more than 2,300 physicians and advanced practice providers with privileges. Committed to its mission of improving health and well-being, ProMedica has received national recognition for its clinical excellence and its initiatives to address social determinants of health. For more information about ProMedica, please visit promedica.org/aboutus.

Provides leadership for ProMedica Laboratories systemwide quality program and resources, ensuring the program integrates with ProMedica’s quality goals, mission, values, and laboratory regulatory agencies’ standards. Oversees Medialab, Quality Management System platform. Leads laboratory specific development, implementation, and data analysis of performance improvement activities as directed by laboratory administration. Collaborates with Medical leadership on laboratory test utilization.

ACCOUNTABILITIES

*All duties listed below are essential unless noted otherwise*

1. Coordinates, provides direction for the system wide laboratory quality program ensuring each of ProMedica’s Laboratories meets or exceeds all CAP, TJC, CLIA and ISO15189 requirements for continuing operations.

2. Oversees analysis of laboratory quality and occurrence management data for trends. Researches and recommends appropriate quality benchmarks and goal targets as relates to laboratory quality monitors, CAP LAP, CAP ISO 15159 & TJC standards, and improvement projects. Identifies improvement opportunities and is responsible for the implementation of action plans.

3. Schedules and facilitates regular management reviews of occurrence management data. Organizes, facilitates, and supports laboratory quality meetings including agenda, minutes, and information packets. Prepares quarterly and yearly laboratory quality reports.

4. Assists data integrity team to ensure each patient’s laboratory medical record is accurate.

5. Oversees and directs the Quality team. Interviews, hires, assigns work duties, establishes goals and performance standards. Ensures effective interdepartmental communication, team building and staff development by using any, and all tools deemed appropriate and necessary including maintaining visibility and accessibility, providing on-going feedback on performance, ensuring an effective annual performance appraisal process, and holding regular departmental meetings. Administers discipline when necessary and recommends discharge when appropriate. Takes ownership of employee satisfaction data; ensures availability to discuss concerns with staff and communicates effectively.

6. Acts as system administrator for MediaLab platform which encompasses laboratory document control system, inspection readiness, competencies, continuing education, and personnel documentation (CLIA).

7. Manages departmental policies and procedures, objectives, quality assurance, safety, environmental and infection control, ensuring alignment with hospital policies.

8. Oversees preparation for and maintenance of ISO 15189 accreditation as well as System CAP LAP accreditation. Schedules and performs audits to ensure continual readiness. Trains other laboratory associates in auditing to assist with continual readiness.

9. Develops and oversees the application of LEAN techniques are applied, as appropriate. Identifies, recommends, and manages improvement action plans.

10. Complies with requirements of accreditation and regulatory agencies by attending mandatory in-services and continuing education. Maintains and upgrades personal professional development.

11. Works with Medical Leaders to determine best practices of laboratory testing. Looks at the current utilization trends, responds to provider requests, and makes recommendations based off data, evidence-based literature, and clinical need. Facilitates, and prepares data for the work teams that looks at frequencies, duplication, and appropriateness of lab testing. Presents the testing recommendations to the appropriate committees.

12. Works with IT to get testing recommendations integrated into the HIS systems. Aids in the education of any testing changes.

13. Performs other duties as directed.