Lab_Director_SOW_29_Apr_2015.docx

PATHOLOGICAL LABORATORY SERVICES

Non-Personal Services

STATEMENT OF WORK

The contracted pathologist must have and maintain current certification in anatomic or clinical pathology, or both, by the American Board of Pathology or American Osteopathic Board of Pathology, or possess qualifications equivalent to those required for certification. The pathologist will provide medical laboratory oversight of clinical support services in accordance with the Clinical Laboratory Improvement Amendment (CLIA) and the College of American Pathologists (CAP) for Moderate/High Complexity Testing Lab, and to assist with maintaining accreditation by CAP. Services include overall operation and administration, such as performance of test procedures, record and reporting accurate and proficient test results, consultation to professional staff, and assuring compliance with applicable regulations.

SERVICES shall be provided via:

1. One (1) scheduled two-hour visit per month.

2. Written summaries of the visits will be prepared and forwarded to the Laboratory Flight Commander no later than 14 days after the visit.

3. Unscheduled visits to consult/evaluate clinical specimens as agreed to by the contracted pathologist and the Laboratory Flight Commander.

4. Unlimited telephone consultations during the timeframe of M-F, 0700-1700.

5. Provide services at all times during the timeframe of M-F, 0700-1700.

RESPONSIBILITIES & DUTIES:

If the lab director reapportions performance of his/her responsibilities, he/she remains responsible for ensuring that all duties are properly performed.

1. Review the qualifications and clinical skills of laboratory personnel.

2. Reviews personnel educational qualifications, documented training and experience, and adequate competency to meet the needs of the laboratory.

3. Ensures proficiency testing, alternative assessment, and QC procedures are sufficient for the extent of testing performed in the laboratory.

4. Review and sign all accreditation, CAP, and other types of surveys/results/recommendations and advise on appropriate changes in procedures in order to correct erroneous or questionable results as necessary.

5. Ensure an effective quality management program for the laboratory.

6. Review laboratory Quality Assurance and Quality Improvement programs and consult with the Laboratory Flight Commander on the programs.

7. Review quality control records and quality assurance documentation.

8. Review and make recommendation on personnel matters, quality control systems, safety, space requirements, and test delivery systems (equipment and supplies).

9. Ensure that the physical plant and environmental conditions of the laboratory are appropriate for the testing performed and provide a safe environment in which employees are protected from physical, chemical, and biological hazards.

10. Ensure that testing systems developed and used for each of the tests performed in the laboratory provide quality laboratory services for all aspects of test performance, which includes the pre-analytic, analytic, and post-analytic phases of testing.

11. Ensure the test methodologies selected have the capability of providing the quality of results required for patient care.

12. Recommend implementation of new laboratory procedures or deleting old ones that may cut cost or time without decreasing the quality of patient care.

13. Ensure verification procedures used are adequate to determine the accuracy, precision, and other pertinent performance characteristics of the method.

14. Ensure laboratory personnel are performing the test methods as required for accurate and reliable results.

15. Act as the final authority when it comes to the approval of studies, and approves implementation of new instrumentation/methods.

16. Ensure communication of laboratory data and appropriate patient result reporting.

17. Review interactions with agencies such as national, state and local health departments, as appropriate, for laboratory-related matters.

Due to the potential immediate need for evaluation of clinical specimens, test results and hematologic slides, the location of the laboratory providing this service must be within 30-minute driving radius of the 30th Medical Group. This is imperative in providing the healthcare teams with a diagnosis, interpretation and treatment within a timely manner.