Lab Hematology Supervisor
Company: South Shore Health
Location: Weymouth
Posted on: April 24, 2024
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Job Description:
Job Description SummaryUnder the general direction of the
Director, and in conjunction with the Technical (Pathologist)
Director and Chief of Pathology, is responsible for the supervision
of the Hematology section of the Laboratory. All duties will be
performed in accordance with established policies, procedures and
standards, and will comply with criteria mandated by appropriate
accrediting and licensing agencies.Job DescriptionESSENTIAL
FUNCTIONS
1. Supervises all work performed within the section. This includes,
but is not limited to, responsibility for quality of all tests
performed, organizing workflow and prioritizing work as needed.
a. Reviews all test results and QC data generated in Hematology,
urinalysis, coagulation and serology as per established criteria by
CAP and other regulatory agencies.
b. Maintains a procedure manual that is accurate, up-to-date and in
compliance with format and content established by Clinical &
Laboratory Standards Institute (formerly NCCLS), CAP and other
regulatory agencies. Review and updates at least annually and
maintains documentation of all changes to procedures. Formally
communicates all procedural changes to staff and documents staff
acknowledgement of these changes.
c. Oversees Instrument Maintenance Program and assures maintenance
is performed, as defined in the policies & procedures. Establishes
written maintenance logs, troubleshooting guidelines, written
problem/resolution logs and works with vendor to assure all
activities, including Preventive Maintenance are performed to
maintain the instruments to perform optimally.
d. Assures that tests are performed within established turn around
times and regularly seeks opportunities to improve service and
meet/exceed patient/client needs.
e. Assures consistently high quality test result records as
evidenced by data review, Quality Control, Proficiency Testing, CAP
Inspections, and feedback from clinician.
f. Assures Competency of Staff in interpreting Quality Control
Data.
g. Develops comprehensive systems to monitor the quality of work.
This plan (QC, QA, & Proficiency Testing) is written and shared
with staff to ensure consistent compliance.
2. In collaboration with other section supervisors, schedules work
assignments and plans work schedules of employees to maintain
consistent and adequate coverage of the entire laboratory.
a. Posts schedule of hematology staff thirty (30) days in
advance.
b. Posts daily assignments in Hematology a weekly basis and updates
to meet the needs of each department to assure adequate
coverage.
c. Meets regularly with Management Team to schedule department wide
staffing issues. Collaborates with peers to assure cross coverage
and that minimum staffing needs are consistently met.
d. Shares in rotation to provide coverage for vacancies, absences,
and paid time off. Is responsible for assuring the adequacy of
coverage.
3. Establishes & maintains an effective inventory control system
that assures inventory levels that consistently meet the demands of
the workload.
a. Prepares laboratory purchase orders and submits for approval.
Adheres to procedures regarding acquisition of, and payment for,
goods and services.
b. Establishes a formal procedure for assessing inventory levels
and involves the staff in participation in this process.
c. Focus is on efficient use of reagents and supplies that is
consistent with workload volume and budgeted resources.
4. Hires, trains, and ensures competency of staff.
a. Orients and trains new employees to perform all procedures
following established protocol. Documents all training of new
employees and completes evaluation form within the 90 day
probationary period.
b. Trains all employees when new procedures, instruments or methods
are established. Provides staff with written and practical
exercises and tools to learn procedures and demonstrate
compliance.
c. Prepares and implements annual Competency Plan and maintains
documentation of technical competency of all staff who perform
testing within the section, as per departmental and Hospital
Competence Policies & Procedures.
d. Documents communications with staff when policies or procedures
are changed or introduced to assure staff understanding and
compliance.
e. Develops performance goals/objectives with each staff member to
promote maximum productivity, proficiency and professional growth,
as evidenced by written goals on performance appraisals.
5. Consistently and fairly implements Human Resources Policies to
promote positive employee relations.
a. Collaborates with Human Resources on the effective recruitment
and selection of qualified employment candidates.
b. Ensures employee compliance with all Hospital & Departmental
policies & procedures.
c. Conducts annual performance evaluations on all departmental
staff. Completes employee performance appraisals thoroughly and
submits on time.
d. Provides ongoing and timely feedback to staff relating to
performance issues. Consistently recognizes employees for
exceptional service to patients and others.
e. Conducts at least one mid-cyle performance assessment for all
direct reports to provide feedback relating to attainment of goals,
performance and behavioral expectations.
f. Keeps the Director informed of significant Performance issues
and seeks counsel as to appropriate courses of action.
g. Follows human resources policies to implement progressive
discipline, when necessary.
6. In collaboration with the Director and Technical Director
(Pathologist), is responsible for the evaluation, selection, and
documentation of testing of all new instruments, methods and
procedures for testing performed in the Hematology section.
a. Serves as primary contact for vendors and makes recommendations
regarding equipment status, reagent costs, service agreements, etc.
Monitors expenditures and performs cost analysis on equipment
purchases/rental agreements.
b. Follows established protocols for implementing new
instrumentation and/or procedures as per CLSI Guidelines.
c. Solicits feedback from physicians & other caregivers as to the
adequacy of testing protocols.
7. Maintains accurate and complete documentation required by
regulatory agencies, including quality control, Performance
Improvement, instrument maintenance service records and other
record keeping requirements of the laboratory licensing and
accrediting agencies and organizations.
a. Is responsible for the performance of all Quality Control
required to maintain precision, accuracy, and quality of testing.
Establishes a comprehensive QC program that is in compliance with
CAP and CLSI Standards.
b. Implements new procedures as needed to ensure compliance with
state regulations and all regulatory agencies (CAP, CLIA,
JCAHO)
c. Documents all QC on a daily basis, submits monthly and quarterly
Quality Control/Assurance reports.
d. Oversees performance of Proficiency Testing (CAP surveys) among
staff, documents results, submits reports at appropriate time,
reviews results with staff, and submits documentation of
investigation and corrective action on all unacceptable performance
challenges. Assures that all staff participate in Proficiency
Testing as part of on-going technical Competency process.
e. Maintains and updates the Hematology laboratory procedure
manuals and protocols, according to Hospital policy and NCLSI
standards.
f. Reviews and signs all procedure in Hematology section on at
least an annually basis according to CAP requirements, JCAHO and
all regulatory agencies.
g. Annually establishes departmental Performance Improvement
Initiatives that are consistent with, and support SSH strategic
planning initiatives and Annual SSH Performance Goals.
h. Identifies opportunities for improvement and incorporates into
formal PI plan that meets JCAHO and other regulatory agency
requirement standards. Collects and reviews data and plans response
to findings.
i. Keeps staff engaged in PI iniatives, and shares quarterly
reports at staff meetings.
8. Responsible for the fiscal management of section; assures proper
utilization of organization's financial resources.
a. Establishes and submits section budget within designated
deadlines according to all budgetary policies and procedures.
b. Effectively utilizes resources within established budget;
notifies Director of all variances anticipated, or incurred.
Identifies and implements actions needed to bring expenses in line
with budget.
c. Performs assessment of the efficiency of the utilization of all
resources in the department, including personnel management,
equipment/reagent evaluation and method development.
d. Prepares bi-weekly FTE utilization reports and budget reports
monthly, and submits responses as scheduled. Responds to variances
and establishes effective action plans to meet departmental budget
goals.
e. Recommends ways to reduce expenditures and/or enhance revenues
without compromising quality of services.
f. Is proactive in managing resources. Regularly runs utilization
reports to monitor expenditures prior to end of cycles to assure
budges are met.
g. In collaboration with the Medical Director, services as a
resource for providing technical guidance to physicians, nurses and
other care-givers.
9. Responsible for section's operational excellence; Manages all
activities to assure section delivers quality services in
accordance with applicable policies, regulatory requirements and
professional standards.
a. Establishes and implements policies and procedures to achieve
departmental objectives, as identified in the Strategic Plan for
the Hospital and Department.
b. Organizes test schedules for the most cost effective and highest
quality production of results, without compromising patient
care.
c. Maintains effective and appropriate staffing. Monitors employee
turnover, overtime and absenteeism and creates a work environment
that recognizes employees for individual and team accomplishments,
and exceptional service.
d. Maintains sectional productivity measurements; reports status
monthly.
e. Is proactive in managing resources. Regularly runs utilization
reports to monitor expenditures( prior to end of cycles to assure
monthly budget goals are met.
f. Consistently monitors ( collects and maintains data) to assess
volume ( high volume/high cost tests) and identifies opportunities
to reduce costs and implement action plans to achieve cost
reductions.
10. Effectively communicates departmental, organization and
industry information to staff.
a. Motivates and encourages professional growth, as evidenced by
annual goal setting and achievement for all employees.
b. Gathers, interprets, and delivers information to staff in a
timely fashion.
c. Conducts departmental employee meetings on a monthly basis and
distributes minutes to staff.
d. Assures staff understands information as evidenced by staff
compliance with, and participation in, hospital programs, seminars,
training and related activities.
e. Communication with staff is effective, resolving conflicts which
may hamper relations and productivity. Promotes open door policy of
communication for all employees.
f. Uses hospital communications resources to inform internal and
external audiences of departmental news/achievements/policies.
g. Meets at least monthly with Medical Director to keep him
informed as to technical and operational issue and to solicit input
in issues such as PI, QC, new methods and instrumentation.
h. Meets bi-weekly with Administrative Director, completes meeting
template and submits 24 hrs to meeting. Keeps Director informed as
to on-going issues and works collaboratively to resolve
operational, technical and administrative issues.
12. Safety Awareness - Fosters a "Culture of Safety" through
personal ownership and commitment to a safe environment.
a. Serves as a role model for all Hospital & Departmental Safety
Standards through consistent compliance with the established Safety
Policies & Procedures (including General Safety, Clinical Hygiene
Plan, Blood Borne Pathogen & other OSHA and Regulatory
requirements).
b. Continually monitors staff for compliance and all Hospital &
Departmental Safety Regulations/Standards. Is responsible for
assuring consistent compliance.
c. Seeks opportunities to improve Patient Safety and encourages the
staff to do the same. Implements changes to existing operations to
support the goal of keeping out patients safety.
d. Seeks opportunities to improve Patient Safety and encourages the
staff to do the same. Implements changes to existing operations to
support the goal of keeping out patients safety.
e. Is responsible for maintaining & updating all Safety Related
Procedures & Guidelines, reviews at least annually.
ESSENTIAL FUNCTIONS (Cont.)
I. Technology and Learning
a. Participates in continued learning and possess a willingness and
ability to learn and utilize new technology and procedures that
continue to develop in their role and throughout the
organization.
b. Embraces technological advances that allow us to communicate
information effectively and efficiently based on role.
NON-ESSENTIAL FUNCTIONS
1. Maintains and updates technical and managerial knowledge and
skills through reading, attending workshops and seminars, and
shares this knowledge with staff to provide continuing education
opportunities for employees at staff meetings.
2. Collaborates with Supervisors, Managers, Directors and
Pathologists in achieving departmental goals. Is an effective team
member and consistently demonstrates behaviors consistent with a
highly functioning team. Shares in the work of the Team, is outcome
focused and follows through with responsibilities assigned to the
Team.
3. Submits, reviews and approves payroll for the section. Monitors
appropriate utilization of Productive & Non-Productive time.
Assures staff compliance with Hospital Pay Practices, Policies &
Procedures.
4. Reports deviations from Policies & Procedures, as appropriate,
using the Hospital Incident Reporting Database. Provides timely and
thorough follow-up and corrective action to all assigned
incidents.
5. Performs work of equal skill and responsibility as directed. May
also perform work of higher level in preparation for increased
responsibility and may be requested to perform work of lesser
responsibility, when work load of section so requires. Performs
bench work in the Hematology section as appropriate.
6. Participates in special project work, as assigned by the
Director of the Department. Performs other tasks as assigned by the
Director or Chief of Pathology. Readily accepts assignments and
completes work, as assigned, on time.
7. Readily accepts assignments and completes work, as assigned, on
time.
8. Manages issues on assigned weekend effectively. Makes
adjustments to assignments, as demanded by workload, initiates
problem solving pertaining to instrument problems or unusual issues
that may arise.
9. Works collaboratively with IS Department (LIS Applications
Specialist) to assure accurate and efficient utilization of
Laboratory MediTech systems.
10. Tests new Meditech codes, and tests interfaces with direction
from Meditech & IS support (Meditech documentation)
11. Builds, maintains, and assures the accuracy of the Meditech QC
program.
12. Assures the accuracy of the test dictionaries (including
billing data) through periodic audits and documents these
activities as per established protocols.
13. Conducts period audits and validation of system calculations
and Normal Ranges as per established protocols.
14. Achieves annual goals, as established at the time of Annual
Performance Review. Attains all agreed to goals and objectives
within specified time frames, as part of the organization's overall
mission. Demonstrates behavior focused on achieving throughout the
year. Requires minimal intervention by the Director to assure that
assignments are complete, accurate, and submitted on time.
Must be knowledgeable and experienced in Hematology, Coagulation,
Urinalysis and Serology testing. Able to establish an effective,
comprehensive Quality Improvement & Quality Control Programs for
the department. Skilled at managing multiple priorities,
organization and interpersonal and communication skills must be
well developed.
Keywords: South Shore Health, Weymouth , Lab Hematology Supervisor, Healthcare , Weymouth, Massachusetts
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