- Location: Charlotte, NC
- Posted: May 31, 2019
Job Req ID: 197179
Position Number: 00132222
Employment Type: Full Time
Shift Details: Monday-Friday 8-5
Standard Hours: 40.00
Department Name: CHSMG PE Lab
Location: Physician Services Group
Location Details: 720 E Morehead Street, will require travel to medical group practices
Carolinas HealthCare System is Atrium Health. Our mission remains the same: to improve health, elevate hope and advance healing - for all. The name Atrium Health allows us to grow beyond our current walls and geographical borders to impact as many lives as possible and deliver solutions that help communities thrive. For more information, please visit carolinashealthcare.org/AtriumHealth
Oversees the daily continuous accreditation readiness for assigned facility(s). Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity.
- Leads continuous accreditation readiness efforts and coaches others in the development of accreditation improvement capabilities. Provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness.
- Maintains expert competence in accreditation standards and communicates relevant changes to appropriate leaders and staff.
- Maintains a close working relationship with facility leadership to optimize the quality and patient safety culture and to support constant state of readiness for accreditation reviews.
- Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities. Compiles and distributes compliance reports including appropriate action plans to oversight councils. Supports and guides the facility in continuous survey readiness efforts.
- Participates in the review, analysis and development of plans.
- Prepares reports and presentations.
- Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity. Re-assesses approach to maximize success.
- Assists leadership in defining key performance indicators and developing measurement tools to evaluate quality improvements.
- Utilizes facilitation skills (both team and individual), data analysis and statistical process control to effect improvement in quality and clinical outcome.
- Consults with and trains staff to implement monitoring and measurement tools, and data analysis techniques. Provides education and training on accreditation compliance and accreditation matters.
- Collaborates with staff to facilitate improvement teams to achieve facility and System quality and patient safety goals.
- Assists with system and regional quality initiatives.
Additional Essential Functions
- Leads continuous CLIA/CMS regulatory compliance readiness for the CHSMG physician office laboratories (POLs); acts as liaison between POLs and CLIA; is present for CLIA surveys and assists with Plans of Correction following survey, if needed. (Planning and execution of TJC annual PP is N/A).
- Compiles and distributes compliance reports including appropriate action plans to CHSMG lab testing personnel and administrators, using Verge tools. (Does not report to QCC. Does not participate in Leadership Conference.).
- Provides training and education for lab testing personnel; responsible for evaluation of testing personnel competency and performance. (does not train staff on data analysis techniques)
Works in an office environment. Requires walking, standing, long periods of sitting and computer use. Intact sense of sight and hearing required. Travels to CHS facilities as needed. Must have current state driver's license.
Education, Experience and Certifications
Bachelors Degree required; Masters Degree preferred. RN or other clinical licensure preferred. Certification in healthcare quality, patient safety or related accreditation entity preferred, required within 1 year of employment.
Additional Training and Certifications
A baccalaureate degree from a regionally accredited college/university in the chemical, physical, biological sciences or medical technology (clinical laboratory science) required by CLIA. Successful completion of CLSI accredited Medical Technology/MLT (Clinical Laboratory Science) Program required.
At least two years lab training /experience or both in a non-waived (moderate or highly complex) lab in the areas of specialty or subspecialty (hematology/chemistry/microbiology) the technical consultant is responsible is for required by CLIA.
At least two years’ experience that demonstrates competency in physician office laboratory practices preferred.
Should have a basic knowledge of CLIA regulatory requirements.
Professional certification preferred.
At least 2 years supervisory laboratory experience in non-waived testing preferred.
Knowledge of PDSA and LEAN concepts preferred
At Atrium Health, formerly Carolinas HealthCare System, our patients, communities and teammates are at the center of everything we do. Our commitment to diversity and inclusion allows us to deliver care that is superior in quality and compassion across our network of more than 900 care locations.
As a leading, innovative health system, we promote an environment where differences are valued and integrated into our workforce. Our culture of inclusion and cultural competence allows us to achieve our goals and deliver the best possible experience to patients and the communities we serve.
Posting Notes: Not Applicable
Carolinas HealthCare System is an EOE/AA Employer
- Full Time