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Manager, Laboratory Quality & Accreditation Program

University of Virginia Health System
Charlottesville, VA Other
POSTED ON 3/9/2025
AVAILABLE BEFORE 5/9/2025
Provide management and oversight of all activities related to the laboratory quality and accreditation programs, which include performance improvement, regulatory compliance, safety, and other educational activities for UVA Medical Laboratories. Leads quality improvement initiatives in support of laboratory activities. Ensures regulatory compliance with CAP, FDA, TJC, CMS, FACT, NACCLS, etc.

  • Plan and direct the implementation, monitoring and evaluation of a comprehensive quality assessment, safety, and performance improvement program for UVA Medical Labs.
  • Ensure effective communication and education of quality outcomes management, safety, and regulatory issues to UVA Medical Laboratory managers and team members.
  • Ensure compliance with applicable regulations, standards, and guidelines related to Laboratory Services.
  • Provide expertise, support, training and education to lab managers and staff in their activities related to process and quality improvement, including investigations, root cause analysis, A3s, LEAN process improvement methods, and corrective action planning.
  • Provide a planned systematic approach to identifying, designing, prioritizing, implementing, measuring, and monitoring quality and operational processes.
  • Facilitate and participate in multidisciplinary workgroups alongside laboratory managers, aiming to systematically resolve quality and patient safety-related issues and to promote the integration of Laboratory initiatives.
  • Provide management oversight to quality program and structure within Laboratory Services, and delegates duties as appropriate.
  • Provide data interpretation and analysis as required in support of quality improvement activities/initiatives.
  • Prepare and present quality assurance reports and performance improvement, reports for inter-departmental quality initiative and committees, root cause analysis, turn-around-times, and other quality metrics to ensure continual improvement of laboratory operations.
  • Support all student educational activities related to partnerships with external facilities and ensure adherence to accrediting agencies.
  • Oversee the coordination of accreditation surveys and ensure readiness for audit at all times.
  • Develop and implement action plans in response to survey/review findings.
  • Provide guidance in the development and maintenance of Human Resource policies and job descriptions to ensure regulatory compliance.
  • Chair regularly scheduled Quality Assurance and Improvement Committee meetings to provide coaching and mentorship to the Quality Team.
  • Chair regularly scheduled Safety Committee meetings to share information related to the Safety Plan.
  • Participate in various Medical Center committees to maintain understanding of policy changes that may affect Medical Laboratories.
  • Act as liaison to the Medical Center Quality department for The Joint Commission and other regulatory agencies.
  • Establish and maintain collaborative relationships with external organizations, including regulatory agencies and quality improvement organizations. Stay informed about industry trends, benchmarks, and best practices in laboratory quality management.
  • In addition to the above job responsibilities, other duties may be assigned.
Position Compensation Range: $76,398.40 - $122,241.60 Annual

MINIMUM REQUIREMENTS

EDUCATION: Bachelor’s Degree with completion of a NAACLS approved MLS/CLS/HTL/CT program preferred, OR Associate Degree in Medical Laboratory Technology from a NAACLS approved MLT/HTL program. Coursework in continuous process and quality improvement preferred.

EXPERIENCE: 3 years of regulatory experience in a complex health environment with increasing leadership responsibilities.

LICENSE/CERTIFICATION: MLS/CLS, CT, HTL, PA or categorical, ASCP or equivalent. RN or other healthcare certifications considered. Certification in continuous process and quality improvement preferred. May require a valid Virginia Driver’s License.

PHYSICAL DEMANDS

Job requires sitting, walking to multiple sites throughout the medical center complex and repetitive motion. May be exposed to fumes, chemicals, radiation, blood/body fluids and infectious disease. This position requires periodic out-of-state travel.

The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library,are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex, pregnancy, sexual orientation, veteran or military status, and family medical or genetic information.

Salary : $76,398 - $122,242

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