POSITION SUMMARY

Responsible for all Quality, Regulatory, Education, and Business Process activities in all Diagnostic Imaging across the Penn Medicine Lancaster General Health (LGH) enterprise. This includes collaboration with the PMR team for Quality and Regulatory activities. Oversight of activities designed to reduce patient care errors, staff injury and other factors that contribute to unintended adverse patient outcomes. Oversees the team that supports these functions including:  quality improvement activities, adherence with all regulatory requirements, and staff education for Diagnostic Imaging services at all sites which include: Duke Street, WBH, Suburban Pavilion, Urgent Cares, all other Ambulatory sites.

Monitors and reports Press Ganey survey results. Chairs the Diagnostic Imaging Quality and Safety Committee.  Facilitates compliance with all regulatory requirements, quality and performance improvement oversight measurement and reporting. Responsible for coordinating annual review of competencies.

HOURS: Full-time, Monday-Friday, Occasional weekends or evenings, participates in Diagnostic Imaging leadership call rotation.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

• Provides leadership for all Quality, Regulatory, Safety, and Edcational activities, ensuring patient and team safety via compliance with all applicable regulatory organizations.Collaborates with the Diagnostic Imaging leadership on the compilation and review of all business functions, including capital and operational budget planning, monthly expenses, and all other applicable financial functions.
• Communicates and collaborates with Diagnostic Imaging physician leadership as well as physicians and other disciplines and departments to maximize quality and safe patient care outcomes in Diagnostic Imaging.
• Represents Penn Medicine Lancaster General Hospital Diagnostic Imaging at the UPHS Radiology Enterprise Clinical Effectiveness Team meetings.
• Assesses and ensures regulatory compliance for all service and safety including but not limited to LGH and departmental Policies and Procedures, TJC standards, PA DOH regulations, ARRT, ACR, FDA, NRC and the professional Code of Ethics. Utilizes evidence-based research to initiate required changes to practices and/or processes.
• Utilizes data based approaches and facilitates innovation and creativity in the development of new initiatives that support ongoing performance improvement activities and organizational change strategies to improve the culture of safety.
• Develops and maintains tracking, trending and reporting of safety and quality indicators across Diagnostic Imaging services. Performs the necessary quality and safety data analysis. Responsible for reporting data to the Diagnostic Imaging Quality and Safety Committee as well as to the UPHS Radiology Enterprise Clinical Effectiveness Team.
• Serves as a liaison to other departments such as, but not limited to, Risk Management, Employee Health, Infection Control and Safety and Environment of Care.
• Participates in activities and on committees in the organization that relate to safety and performance improvement. Participates in the organization of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and committees related to patient and employee safety. Collaborates with Diagnostic Imaging leaders on the RCA action steps and monitors that action steps are completed by responsible modalities.
• Ensures the Diagnostic Imaging department is updated on all National Patient Safety Goals (NPSG) and medical staff compliance to Department of Health’s (DOH) / Joint Commission patient safety regulations. Authority to assess, evaluate, develop and implement changes for patient and employee safety within the Diagnostic Imaging Department and teams using a collaborative process.
• Initiates and oversees the development of a comprehensive Diagnostic Imaging Department patient safety improvement program inclusive of the analysis and trending of data related to department and organizational initiatives.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

• Serve as liaison on the system-wide Penn Medicine Radiology Clinical Effectiveness Team which includes participation and preparation of the annual LGH Diagnostic Imaging Department Quality activiti
• Maintains professional acumen, participates in professional organizations, maintains continuing education as required by professional certification boards.
• Participates on applicable Hospital Committees as requested.
• Other duties as assigned.

JOB REQUIREMENTS

MINIMUM REQUIRED QUALIFICATIONS:

• Bachelor’s degree in business or a health related field is required.
• Certification in a clinical discipline by one or more certifying bodies.
• Minimum of five (5) years experience in Diagnostic Imaging operations.
• Minimum of two (2) years of experience serving in a leadership role.
• Demonstrated skills in leadership, planning, quality program development, and regulatory evaluation.

PREFERRED QUALIFICATIONS:

• Master’s degree, preferably in a healthcare, education or quality field.
• Experience in healthcare project management in an acute care hospital setting preferred.
• Crew Resource management education.
• Lean education, training or certification.

COGNITIVE REQUIREMENTS

Attention/Concentration: The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others.  

• The position requires strong concentration skills.  The individual must have the ability to voluntarily sustain concentration to a task over an extended period of time as a result of an effortful and usually deliberate heightened and focused state of attention.

New Learning and Memory: The following level of ability is essential for the jobholder to learn and retain material.

• A large portion of this position requires reliance on verbal memory and new learning.  Efficiency in processing of verbal information, either in written or spoken form, is a major requirement and prerequisite of the job.  The individual must be able to attend to and process multiple bits of information simultaneously.  The individual must be able to organize and categorize this information effectively so that later recall is feasible.

Problem Solving, Reasoning and Creative Thinking: The following level of ability that is essential for the jobholder to think (in order to solve a problem) by combining two or more elements from past experience or imaginative thought.  

• The position requires much autonomy of thought and problem solving.  The individual must be able to apply principles of logical or scientific thinking to define problems.  The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem.  The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis.  The individual must be able to collect data, establish facts, and draw valid conclusions.  The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition.  They must be able to deal with a variety of concrete and abstract variables.

APTITUDES:  The following are essential requirements of the position in relation to job-worker situations.  These items describe how a worker must adapt, adjust, conform or act.  

Leadership, control and planning: Ability to accept responsibility for leadership, direction, control, planning, negotiating, organizing, directing, supervising, formulating practices, or making final decisions.

Performing under stressful conditions: Ability to perform under stress when confronted with emergency, critical, unusual, or dangerous situations, or in situations in which working speed and sustained attention are critical aspects of the job. Is subject to danger or risk, or to tension as a regular, consistent part of the job.

Variety and change: Ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure involving significant differences in technologies, techniques, procedures, environmental factors, physical demands, or work situations.

Communication:  Ability to exchange information with others clearly and concisely; to present ideas, facts and technical information.

Interpersonal relations: Ability to maintain relationships that facilitate task accomplishment; to cooperate and resolve conflicts; to recognize needs and be sensitive of others.

EQUIPMENT USAGE REQUIREMENTS

Equipment/Tools: Computer, Phone, Copier, Printer, Fax, Office Supplies

Software: Microsoft Office Products, Healthcare systems including but not limited to Epic, Change Healthcare PACS, PeerVue, etc.

PHYSICAL REQUIREMENTS

Rarely 0-10%; Occasionally 11-35%; Frequently 36-70%; Continuously 71-100%

Body Position/Movement:

• Sit:                          Frequently
• Stand:                    Occasionally
• Walk:                     Frequently
• Bend:                     Rarely
• Push:                      Rarely
• Pull:                        Rarely
• Kneel/Squat:        Rarely
• Reach:                   Occasionally
• Twist:                     Occasionally
• Balance:                Rarely
• Climb:                    Rarely

Lifting: Degree of physical exertion is:  Light, exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to move objects.

Sensory Abilities specifically required:  

• Vision
• Hearing
• Touch/Feeling

PHYSICAL ENVIRONMENT

WORKING CONDITIONS:   

Position involves exposure to the following harmful elements:

• Bio hazardous Waste
• Blood borne Pathogens
• Chemicals
• Radioactive Agents

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.