Manager, Blood Bank and Lab Quality - Transfusion Service

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Date: Jul 19, 2019

Location: Newport Beach, CA, US

Company: Hoag Memorial Hospital Presbyterian

Job Description:

  • The Blood Bank and Laboratory Quality Manager is responsible for the management and supervision of the Transfusion Service division of the Department of the Pathology and Laboratory Medicine.
  • This management and supervision includes oversight over the technical, regulatory, information systems, human resources and budgetary aspects of the Transfusion Service at Hoag Hospital Newport Beach (HHNB).
  • The Blood Bank and Laboratory Quality Manager will work in close conjunction with the HHI Laboratory leadership team to standardize equipment and processes, synchronize projects, ensure regulatory compliance and identify cost savings opportunities.
  • The Laboratory Quality Manager ensures regulatory readiness of the Clinical Laboratory and the execution and continuous improvement of the Laboratory Quality Plan.
  • The Blood Bank and Laboratory Quality Manager will project an image of professionalism in communication, appearance, and conduct while supporting the mission of the department and the organization.
  • In addition to the job specific essential functions listed below, will perform other duties as assigned.


Job Specific Essential Functions:


Technicial Management:


  • Selects test methodologies, instrumentation and scope of service in conjunction with the Medical Director and Laboratory Administrative director.
  • Ensures availability of clear, concise and regulatorily compliant standard operating procedures that reflect current process for all departmental functions.
  • Resolves technical problems and ensures that remedial actions are taken whenever test systems deviate from the performance specifications or during instrument downtime and ensures proper functioning before resuming testing.
  • Identifies need for LIS enhancements and participates in enterprise LIS optimization and upgrade initiatives including testing and documented validation plans.
  • Completes process validation plans for new test methods and instruments.
  • Ensures accuracy, validity and timeliness of testing and blood product availability.
  • Ensures transfusion-related nursing policies and procedures reflect current practice.
  • Directs and reviews antibody identification workups.
  • Oversees Thromboelastograph (TEG) testing program.
  • Establishes and maintains a quality control program appropriate for the testing performed in the preanalytic, analytic and post-analytic phases including IQCP where indicated.
  • Ensures proper validation of blood bank information system when indicated.
  • Maintains Code RBC case metrics and participates in interdisciplinary Code RBC case reviews and the Code RBC Core Committee.
  • Oversees physical lab environment.
  • Keeps Medical Director informed of physician complaints, physician optimization or new test requests, requests for consultations or test interpretation, progress on new process validations, SOP variances and anything that may impact patient care.
  • Maintains close relationship with blood supplier vendor with meets regularly with them to review performance, resolve service issues and discuss service enhancements.
  • In conjunction with the Blood Bank Medical Director, develops and implements patient blood management and utilization review initiatives.
  • Stays up to date with the current Transfusion Medicine literature and issues impacting the practice of Transfusion Medicine.


Budget & Fiscal Management:


  • Develops annual operating and capital equipment budgets for the Transfusion Service and completes budget and productivity variance analysis as requested.
  • Completes unplanned capital equipment requests with thorough justification as indicated.
  • Maintains accurate chargemaster and CPT coding and monitors billing and revenue.
  • Adjusts staffing according to workload and productivity measures.
  • Ensures all contracts are up to date and maintains electronic contract documentation, participates in contract negotiations.
  • Maintains blood use statistics and monitors preventable blood component losses.


Management of Human Resources:


  • Supervises section employees including hiring, work assignments, orientation and training.
  • Manages personnel consistent with Human Resource and Hospital policies, performs coaching and counselling as required and works to establish a culture of trust and accountability and to make staff feel valued and respected at all times.
  • Promptly address performance and behavioral issues.
  • Maintains open communication with staff by leading huddles and staff meetings, seeks input, involves staff in decision making, and keeps them informed of departmental goals, quality metrics and projects in flight.
  • Helps each individual understand how his/her work is important to the success of the team and the organization by communicating hospital updates and linking the work of the Laboratory to the hospital value index.
  • Completes performance reviews and clinical ladder evaluations in a timely manner.
  • Participates in regular bi-campus team meetings with Core Laboratory Supervisors, Leads and Technical Specialists.
  • Ensures appropriate project resourcing.
  • Develops staff through assignment of projects and responsibilities matching their interest and skills and provides review of work, feedback, encouragement and coaching.
  • Provides recognition for and celebrates project completion and noteworthy performance.




Monitors the licensing and accreditation renewal process.

 Maintains the CAP activity menu, CAP facility data and CAP proficiency subscriptions.

Ensures regulatory readiness through midcycle inspection, review of non-conforming events, targeted audits and pre-inspection evidence of compliance documentation for all areas of the Clinical Laboratory.

In conjunction with the Administrative Assistants, maintains and is a resource for the electronic document control system.

Leads CAP, FDA, State and DNV accreditation activities affecting the department and coordinates inspection team when assigned to conduct CAP inspection of other facilities.

Keeps up to date with and communicates changes in regulatory requirements including CAP checklist item, FDA Guidance Documents, California state law and DNV requirements impacting the Laboratory.


Quality and Improvement:


  • Develops agenda for and chairs the Laboratory Quality Council.
  • In conjunction with the Medical Director, Laboratory Administrative Director and Section Managers, conducts review and trending of non-conforming events.
  • Coordinates and analyzes the Laboratory Key Indicators of Quality.
  • Directs quality improvement activities based on risks and trends identified via non-conforming events and key indicators of quality.
  • Continuously reviews, improves and ensures execution of the Laboratory Quality Plan.
  • Prepares and presents annual reports to laboratory and hospital quality and regulatory committees as requested.
  • Works to standardize best practices and documentation systems across all sections of the Laboratory and across campuses.
  • In collaboration with the education coordinator and department managers, provides targeted education opportunities for Laboratory staff.


Job Qualifications:


Education, Training and Experience:


Required: College graduate with a Baccalaureate degree in a major science or equivalent. Must meet and maintain current State of California licensure requirements for Clinical Laboratory Scientist. Must have 3 years’ experience as a Clinical Laboratory Scientist in Transfusion Medicine.


Preferred: MT(ASCP) SBB, previous experience with quality assurance, process improvement and regulatory compliance.


Skills or Other Qualifications:


Required: Demonstrates and maintains current technical knowledge in the field of Transfusion Medicine as it relates to operations of the department. Demonstrates strong written and verbal communication skills. Shows aptitude for writing detailed policies, procedures and report required to comply with AABB, CAP, DNV, FDA, and State of CA standards. Demonstrates skills in interpersonal relationships. Knowledge of proper body mechanics, safety measures and infection control. Demonstrates effective communications and interpersonal skills with all levels of staff and physicians. Demonstrates organizational ability.


License and Certifications:


Required: A valid California Bioanalyst or Clinical Laboratory Scientist license issued by the State of California. Quality Process Improvement or Compliance officer certification.

Preferred: Quality Process Improvement or Compliance officer certification.


Position Reports to: Administrative Director, Clinical Laboratory; Indirectly supervised in medical and regulatory issues by Medical Director Transfusion Service


Position Supervises: Clinical Laboratory Scientists, Lead Clinical Scientists and Non Licensed Laboratory staff


Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Medical, Pathology, Service Manager, Laboratory, Healthcare, Customer Service, Quality, Science

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