Baylor St. Luke’s Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care neuroscience oncology transplantation and more. Our team’s efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment our new McNair Campus is designed around the human experience—modeled on evidence-based practices for the safety of patients visitors staff and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care research and education. Our strong alliance with Texas Heart® Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve.

Job Summary / Purpose

Works with the Laboratory Management Team to organize, plan and coordinate Quality Assurance and Process Improvement activities utilizing Lean design principles and application of best practices. Must ensure that all sections of the laboratory are fully compliant with CAP, CLIA, Joint Commission and any other applicable accreditation or regulatory agency standards.

Essential Key Job Responsibilities

1. Evaluate laboratory workflow and processes. Identify and implement process improvement opportunities using LEAN and/or Six Sigma principles.
2. Institute practice to gather staff feedback and ideas for process improvement
3. Develop project plans to institute process improvements and track progress
4. Hardwire process improvement through continuing education and feedback
5. Work with Laboratory Director and Manager to track progress of process improvement initiatives
6. Interpret and implement quality assurance standards, evaluate existing laboratory policies and procedures, and determine effectiveness of quality assurance program
7. Work with the Laboratory Management Team to ensure that section-specific quality assurance programs meet accreditation requirements, yield useful information and contribute to the overall laboratory quality program.
8. Select specific topics for review, including new procedures/programs, high-risk and high-volume tests, and recurring areas of concern from regulatory and accreditation activities
9. Compile statistical data and produce narrative and graphical reports summarizing quality assurance and process improvement activities
10. Work closely with the Laboratory Management team and Laboratory Medical Director to conduct regular assessments of survey readiness, including mock inspections, in-services and quality record review and audits.
11. Work with the Laboratory Management team on specific projects, including space optimization, regulatory compliance and hospital-wide process improvement activities.
12. Facilitate the preparation of formal corrective actions, audit-related corrective actions and preventive actions and ensure they are implemented in a timely manner.
13. Support Laboratory and Employee safety program
14. Support events related to the Laboratory Proficiency Testing program.