Job Code:	1333
Job Title:	Pathology Quality Management Specialist
Creation Date:	04/18/09
Revision Date:
FLSA Status:	Exempt

JOB SUMMARY:

To serve as a facilitator of quality assessment activities for Pathology Clinical Services to include laboratory sections, patient safety initiatives, regulatory and accreditation compliance, risk management, laboratory safety, and performance improvement. Works with laboratory divisions to develop plans and policies for improved quality throughout the department, and works with top management and leadership to ensure compliance with regulatory agencies.  Coordinates reporting for Pathology’s quality management and improvement programs.  Ensures compliance with the Hospital Performance Improvement Plan, Quality Improvement Plans, Joint Commission Accreditation Standards, College of American Pathologists (CAP), Centers for Medicare and Medicaid Services (CMS), Clinical Laboratory Improvement Amendment (CLIA) requirements, and other accrediting agency requirements. Relies on extensive experience, judgment and self-initiative to plan and accomplish goals.

ESSENTIAL JOB FUNCTIONS:

• Organizes quality management activities for Pathology Clinical Services.
• Participates in the monitoring, reporting, and improvement activities related to clinical guidelines, healthcare quality/safety initiatives, accreditation and regulatory requirements, in collaboration with clinical staff and leadership.
• Provides guidance in the analysis of departmental activities related to HIPAA compliance and other compliance related matters. 
• Monitors and advises on the performance of the quality management system, and produces data and report on performance, measuring against set indicators.
• Acts as a liaison with management and staff throughout the department to ensure that the QA system is functioning properly.
• Researches and identifies process improvements and help set standards and define best practices for Pathology.
• Organizes, attends and facilitates departmental quality management meetings.  Uses data to assist departments in making process changes.
• Collaborates with other departments, such as Institutional Compliance and Health Information Management to ensure compliance with specific HIPAA privacy requirements.
• Educates and assists clinical labs in developing appropriate ongoing quality management/monitoring programs.
• Ensures compliance of areas of responsibility with CMS, Joint Commission, CAP and other accrediting agency requirements.
• Facilitates continuous process improvement teams using the Focus Analyze Develop and Execute (FADE) methodology
• Assists in the development, interpretation, and implementation of departmental policies
• Facilitates proactive and reactive patient safety activities including Root Cause Analyses (RCA), Failure Mode Effects Analyses (FMEA) and Sentinel Event Alerts in regard to the facilitation process, planning, implementation and evaluation of effectiveness of process changes.
• Adheres to internal controls and reporting structure.

MARGINAL OR PERIODIC JOB FUNCTIONS:

• Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of developmental needs that contribute to the enhancement of patient care.
• Communicates PI and quality/safety activities to leadership and QM staff. 
• Performs related duties as required.

REQUIRED EDUCATION / EXPERIENCE:

• Bachelors of Science  or equivalent in related field
• Four years clinical experience which includes one year experience in quality management and process improvement or comparable experience.

EQUIPMENT:

Standard office equipment.

WORKING ENVIRONMENT/LOCATION OF POSITION:

Standard hospital, clinical, laboratory and/or office environments.  May be exposed to such occupational hazards such as communicable diseases, harmful chemicals, and/or disoriented or combative patients. Periodically travels to outlying hospital clinics to conduct audits to assess compliance with regulatory and accreditation standards.

OTHER:

Specific job requirements or physical location of some positions allocated to this classification, may render this position security sensitive, and thereby subject to the provisions of Section 51.215, Texas Education Code.

 ANY QUALIFICATIONS TO BE CONSIDERED AS EQUIVALENTS IN LIEU OF STATED MINIMUMS REQUIRE THE PRIOR APPROVAL OF THE VICE PRESIDENT FOR HUMAN RESOURCES AND EMPLOYEE SERVICES.