Lahey Health Mgr Quality & Compliance CSPD in Burlington, Massachusetts
Welcome to Lahey Hospital & Medical Center, part of Beth Israel Lahey Health. Lahey Hospital & Medical Center is a world-renowned tertiary medical center known for its innovative technology, pioneering medical treatment and leading-edge research. A teaching hospital of Tufts University School of Medicine, the hospital provides quality health care in virtually every specialty and subspecialty, from primary care to cancer diagnosis and treatment to kidney and liver transplantation. It is a national leader in a number of health care areas, including stroke, weight management and lung screenings, among many others. Lahey also helps to advance medicine through research and the education of tomorrow's health care leaders.
About the Job
Position Summary:The Manager of Quality & Compliance, Central Sterile Processing Department ensures that the CSPD Department across bothcampuses are measuring the quality of work being performed. This position will work closely with the Central Sterile ProcessingDirector and Educator in identifying trends in errors, IUSS rates, and safety reporting and developing mitigating strategies.Essential Duties & Responsibilities: including but not limited to:? Assist in policy, process or practice guideline, protocol design, data collection, data analysis, datareporting and feedback to support quality and safety with patient care? Facilitates user support and participation in performance improvement initiatives.? Supervision of Staff: Supervises assigned staff including but not limited to the decontamination,sterilization and preparation of instruments and equipment. Informs Director of issues as appropriate.? Compliance: Ensures that policies, procedures, quality assurance, and customer service standards arefollowed. Participates in the development and implementation as well as the monitoring of alldepartment policies, procedures, technical guidelines and quality assurance standards. Ensures qualityperformance, customer satisfaction and adherence to the requirements of regulatory agencies.? Human Resources: Responsible for maintaining adequate staffing levels, interviewing, and employeerelations. Responsible for completion of staff Performance Appraisals, Competence Assessment,Compliance and Mandatory Education. Counsels and disciplines assigned staff as needed, preparingproper supporting documentation and recommending changes in personnel status.? Manages the Central Sterile Processing department Instruction For Use (IFU) library by utilizing variousdifferent methods (OneSourceDocs; working directly with Vendors; etc)? Act as department representative in various committees throughout the organization (InfectionControl, Surgical Site Infection, DASH, ad hoc, etc)? Works in conjunction with the repair vendor, CSPD supervisors, and OR teams to ensure sets are beingmaintained utilizing Preventative maintenance program based on set usage? Responsible for all task auditing along with a close out process by month ensuring all sterilization andHLD records are complete and organized.? Trends in IUSS documentation, safety reporting, and feedback forms
2 Revised March 2021Printed:? works collaboration with the CSPD Director and CSPD Educator works to identify trends andremediation strategies
? Works with Director and Educator to establish a Department Productivity Standard to measure qualityoutcomes in decontam, prep & pack, sterilization, case pick, equipment (pumps)? Acts as the qualified documentation and regulatory resource person as it pertains to the departmentsfunction for staff, colleagues, and regulatory agencies? Monitors compliance with various regulatory agencies and standards such AAMI standards; AORNstandards; TJC; CMS; DPH; OSHA; etc? Work hands-on in the department in each of the functional areas, leading by example, and is able toperform as a fully functional Sterile Processing Technician.? All other duties and responsibilities as assigned.? Tracking System/Database administration? Develop and maintain a cleaning verification program using 3M ATP testing for surgical instrumentsand Scope Cleaning efficacy.Professional Growth / Self Improvement:? Engages in professional development activities such as education, participating in professionalassociations, or other appropriate activities.? Maintains necessary continuing education requirements for license, certifications and enhancements.
Education: Bachelor Degree Preferred or equivalent experienceLicensure, Certification, Registration: IAHCSMM or CBSPD CertificationSkills, Knowledge & Abilities: Ability to work in a hospital environment and deal closely and effectively with avariety of staff (physicians and nurses, infection control practitioners, CPD staff, risk management,administration) up to 100% of work time.? Experience with working in OR and CPD environment? Requires interpersonal skills necessary to lead, coach and educate others and to work effectively with awide variety of hospital and outside personnel.? Must possess excellent verbal and written communication skills.? Must be proficient with Microsoft Office.
Experience: A minimum of five years of experience in Extensive central processing
Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.
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