Preferred Skills: Be willing and able to travel to all the Medical Centers in the region. Flexible on main office location, as location is subject to change. Be flexible to travel in DC, Montgomery County, and PG county.
PURPOSE: Manages, coordinates and has accountability for all quality assurance and improvement activities to ensure compliance with all federal, state, and local regulations, requirements, and policies for mammography services.
This position consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to the applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures. In addition, Regional leaders are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.
Accountabilities:
1. Leads the development of a quality of care and service program descption, evaluations, and work plan for all KPMAS Mammography, Stereotactic and Breast Ultrasound Services.
2. Is responsible for managing the end- to-end process for Mammography, Stereotactic and Breast Ultrasound Services.
3. Manages all staff within the department: Mammography Coordinators, Nurses and Breast Trackers.
4. Monitors adherence to policies regarding accreditation standards from ACR, FDA/ MQSA, as well as state regulations for Maryland, Virginia, and the District of Columbia.
5. Formulates policies, procedures, and principles in collaboration with the Director and the Chief of Radiology.
6. Performs internal departmental audits, presents results and follow up action plans.
7. Develops, monitors, trains, and implements mammography QC program region wide.
8. Develops monitoring tools and identify parameters to assess quality and establish consistency ' throughout the region.
9. Ensures adherence to currently established departmental policies, procedures, and guidelines.
10. Designs, implements and conducts training programs based on Quality Improvement data; analyzes data from competency-based assessments.
11. Assists mammography staff in the medical centers in the development of competent clinical skills.
12. Establishes and maintains Mammography Quality Management programs.
13. Monitors ongoing quality data, and generates reports based on quality activities.
14. Designs, measures, assesses, and implements the improvement cycle for Quality improvement activities.
15. Conducts audits of radiologist feedback data, repeat/reject analyses, mammography call-back statistics, etc.
MINIMUM REQUIREMENTS ? Relevant Years of Experience:
? Six years of clinical mammography experience required.
? Eight years of experience in a management role in Mammography service required.
? Previous experience in quality management required.
? Knowledge of federal, state and local regulations regarding mammography required.
Education and/or Classes:
? Bachelor's Degree in Health Care or related field required; however, combination of education and equivalent years of experience will be considered.
? Master?s Degree in health care administration, business administration, or related field preferred.
License, Certification and/or Designation:
? ARRT certification required
? ARRT(M) required
