Manager, Pathology Quality, Safety & Regulatory Compliance

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Overview

Under the direction of the Director of Anatomic Pathology, the Manager, Pathology Quality, Safety & Regulatory Compliance is responsible for the development, implementation, maintenance, and continuous improvement of the Anatomic Pathology Quality Management Program, Regulatory Compliance Program, Accreditation Readiness Program, Patient Safety Program, Staff Safety Compliance Program, and Performance Improvement Program. This position supports all Anatomic Pathology divisions and partners closely with the Senior Manager, Operational Excellence & Safety and AP leadership to ensure alignment between quality outcomes, regulatory compliance, accreditation readiness, and operational performance.

Quality Management & Performance Improvement

• Develop, implement, and maintain the AP Quality Management Program. Serves as owner of the Anatomic Pathology Quality Management Plan (QMP) and coordinates annual quality planning, quality management reviews, and quality program evaluations.

• Establish quality indicators, dashboards, scorecards, and performance metrics.

• Oversee CAPA processes and continuous improvement initiatives.

Regulatory Compliance & Accreditation Readiness

• Lead inspection readiness for CAP, CLIA, NYS, Joint Commission, OSHA, and CMS requirements.

• Coordinate mock inspections, audits, and corrective action plans. Serves as the departmental lead for accreditation readiness, regulatory inspections, mock inspections, and compliance monitoring activities across all AP divisions.

Patient Safety, Staff Safety & Risk Management

• Coordinate AP patient safety and staff safety compliance programs.

• Lead RCA, FMEA, and event investigations.

• Monitor trends and develop risk mitigation strategies.

Hospital-Level Specimen Event Collaboration

• Serve as the primary AP liaison for hospital-level specimen events.

• Coordinate multidisciplinary corrective action plans.

High Reliability Organization (HRO) & Safety Culture

• Lead HRO implementation and Just Culture initiatives.

• Promote safety culture and proactive risk identification.

Laboratory Safety Compliance

• Oversee laboratory safety compliance programs and audits.

• Monitor PPE, chemical safety, sharps safety, ergonomics, and bloodborne pathogen compliance.

Document Control & MediaLab Governance

• Serve as departmental MediaLab administrator.

• Oversee policy lifecycle management and document control.

Governance, Reporting & Leadership

• Serve on the AP Leadership Team.

• Represent AP on institutional quality, safety, and regulatory committees.

• Partner closely with the Senior Manager, Operational Excellence & Safety.

Required Skills and Abilities

1. Ability to lead event investigations, risk mitigation efforts, and High Reliability/Just Culture initiatives, promoting proactive hazard identification, near-miss reporting, and sustainable safety improvements across AP divisions.

2. Demonstrated ability to establish quality indicators, dashboards, scorecards, and performance metrics, and lead continuous improvement initiatives across AP divisions.

3. Strong leadership skills to partner with AP and hospital stakeholders, represent AP on institutional quality, safety, and regulatory committees, and coordinate multidisciplinary action plans for specimen events and other high-priority risks.

4. Ability to maintain inspection-ready records and develop clear, well-organized compliance documentation for auditors, inspectors, leadership, and regulatory reviews.

5. Demonstrated skill leading change across multiple AP divisions by aligning stakeholders, standardizing workflows, training staff, and sustaining improvements through monitoring, audits, and performance reporting.

Preferred Skills and Abilities

1. Bachelor’s degree in medical laboratory science, Healthcare Administration, Public Health, Laboratory Science, or related field.

2. Proven experience in Anatomic Pathology, Laboratory Medicine, or academic healthcare environments.

3. Master's degree preferred.

4. CPHQ or ASCP Certification preferred.

Principal Responsibilities

1. Under minimal direction of the Chief Medical Officer, oversee the advancement and growth of the Pay for Performance Quality Program initiatives.  Give direction and leadership supporting the mission, strategy, and annual goals and objectives. 2. Assumes primary accountability for disseminating all program information to create awareness and support of the program. 3. Works closely with leadership, internal and external colleague to further develop and implement strategic plans. 4. Monitoring metrics on the risk/success of the programs. 5. Tracks all program activities and regularly informs leadership of progress on each initiative. Recommends structural or programmatic adjustments, changes or additions based on full knowledge of missions, goals, and objectives. 6. Participate in management meetings.  Work with the departmental management to develop agenda, track issues and follow and address departmental concerns related to areas of responsibility. 7. Work directly with the physicians and the department leads to ensure Pay for Performance compliance. 8. Work closely with YNHH and YNHHS counterparts on joint initiatives related to Pay for Performance Quality Programs.  9. Define and document current and future business needs. 10. Manages the schedule of the projects aggressively with the objective of meeting project targets. 11. May perform other duties assigned. Required Education and Experience Bachelor's Degree and 6 years of experience; or an equivalent combination of education and experience.

Job Posting Date

07/21/2026

Job Category

Manager

Bargaining Unit

NON

Compensation Grade

Administration & Operations

Compensation Grade Profile

Manager; Program Leader (25)

Salary Range

$82,000.00 - $131,500.00

Time Type

Full time

Duration Type

Staff

Work Model

On-site

Background Check Requirements

All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. For additional information on the background check requirements and process visit "Learn about background checks" under the Applicant Support Resources section of Careers on the It's Your Yale website.

Health Requirements

Certain positions have associated health requirements based on specific job responsibilities. These may include vaccinations, tests, or examinations, as required by law, regulation, or university policy.

Posting Disclaimer

Salary offers are determined by a candidate’s qualifications, experience, skills, and education in relation to the position requirements, along with the role’s grade profile and current internal and external market conditions.

The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the position. Employees will be assigned specific job-related duties through  their hiring department.

The University is committed to basing judgments concerning the admission, education, and employment of individuals upon their qualifications and abilities and seeks to attract to its faculty, staff, and student body qualified persons from a broad range of backgrounds and perspectives. In accordance with this policy and as delineated by federal and Connecticut law, Yale does not discriminate in admissions, educational programs, or employment against any individual on account of that individual’s sex, sexual orientation, gender identity or expression, race, color, national or ethnic origin, religion, age, disability, status as a special disabled veteran, veteran of the Vietnam era or other covered veteran.

Inquiries concerning Yale's Policy Against Discrimination and Harassment may be referred to the Office of Institutional Equity and Accessibility (OIEA).

Note

Yale University is a tobacco-free campus.