Quality, Infection Control & Risk Manager – Ambulatory Surgery

Main Function:

Contributes to the fulfillment of the organization’s mission and philosophy by assisting in the analysis, implementation, and evaluation of the quality program. Responsible for the progress and maintenance of organization-wide performance-improvement, risk management, and infection control programs.

Duties and Responsibilities:

1. Philosophy

• Supports the facility’s ideology, mission, goals, and objectives
• Performs in accordance with the facility’s policies and procedures
• Follows the facility’s standards for ethical business conduct
• Conducts self as a positive role model and team member
• Recognizes patients’ rights and responsibilities and supports them in performance of job duties

2. General

• Participates in facility committees, meetings, in-services, and activities
• Punctual and comply with attendance guidelines
• Gets along well with all employees and respects the rights of other employees
• Demonstrates resourcefulness, independent thinking and seeks additional challenges and opportunities. Seeks to create new methods, techniques and processes.

3. Communication

• Communicates effectively and professionally with vendors, physicians, coworkers, patients and visitors
• Interacts with others in a positive, professional, respectful, and considerate manner
• Checks and responds to emails in a timely and efficient manner

4. Financial practices

• Uses facility resources appropriately and avoids wasteful practices
• Reports wasteful practices
• Analyzes work area and makes recommendations for potential cost-effective improvements

5. Compliance program

• Assists in the implementation and maintenance of the organization’s adopted compliance program
• Performs according to established compliance policies and procedures

6. Safety/risk-management program

• Adheres to safety policies and procedures in performing job duties and responsibilities
• Reports observed or suspected safety violations, hazards, and policy/procedure noncompliance to the safety officer or other designated person
• Complete annual education requirements

7. Professional competence

• Participates in continuing education and other learning experiences
• Shares knowledge gained in continuing education with staff
• Maintains membership in relevant professional organizations
• Seeks new learning experiences by accepting challenging opportunities and responsibilities
• Welcomes suggestions and recommendations

8. Regulatory

• Remains current on all applicable state and federal laws, rules, regulations, professional standards and accreditation standards
• Submits required reports on a timely basis
• Develops, interprets and recommends implementation of policies, procedures, regulations, programs and recommended practices to ensure requirements are met

9. CQI/Performance-improvement program

• Assists in the development and implementation of the organization's adopted performance-improvement program
• Maintains and updates organization-wide performance-improvement programs, policies, and procedures
• Performs according to established performance-improvement policies and procedures
• Contributes to the performance-improvement process and identifies his or her role and contributions upon supervisor's request
• Organizes and participates in committees, educational programs, and performance-improvement activities
• Contributes to the evaluation of the performance-improvement program and recommends appropriate revisions, if applicable
• Develops effective data collection, organization, and evaluation systems for monitoring the quality of patient care
• Summarizes collected data and reports findings and recommendations in a timely manner to the performance-improvement committee
• Coordinates performance-improvement activities and communicates outcomes to appropriate committees and individuals
• Assists in the evaluation of patient, employee, and medical staff grievances to identify ways to improve patient care and performance standards
• Identifies resources required for the performance-improvement program and submits resource requests to the governing body
• Assists in identifying important indicators, establishing thresholds, and setting timeframe for evaluation
• Maintains performance-improvement status log
• Serves as an educational resource for performance improvement and keeps facility current on state and federal rules and regulations and accrediting-body requirements
• Maintains performance-improvement records in a confidential and organized manner

10. Infection Control

• Be familiar with facility policies and procedures
• Surveillance, prevention, and control of infection
• Identify and reduce risk of acquiring and transmitting infections among patient, employees, physicians and other independent practitioners, contract workers, students and visitors
• Coordinate infection control programs and educates staff
• Oversees and coordinates with Inservice Coordinator annual evaluation of TB on all employees
• Maintain record of exposures, infections tracking and trending, quarterly documentation and reporting to quality Committee and the Governing Board
• Ensures that all personnel/employees comply with infection control policies in conjunction with the Administrator
• Continual monitoring of high risk and problem prone areas.
• Work with staff/employees to analyze the patterns and trends to identify and determine whether a problem or opportunity for improvement exists

Requirements and Qualifications:

• Cooperative work attitude toward co-employees, management, patients, visitors, and physicians
• Ability to promote favorable facility image with physicians, patients, insurance companies, and general public
• Ability to make decisions and solve problems

Required

• RN degree
• Training/experience in performance-improvement/risk-management; certification preferred
• Training/experience in project coordination and completion
• Training/experience in healthcare
• Strong ethical and moral character references
• Language skills adequate for high-level written and interpersonal communication

Preferred

• Bachelor’s Degree

BENEFITS:

• Health Insurance with FREE Teladoc services
• Dental, Vision, & Supplemental Insurance
• 401(k)
• Paid Time Off with Rollover and Cash Out Option
• Paid Holidays (Including employee’s birthday and an additional personal day)
• Tuition Reimbursement
• Adoption Assistance
• Employee Assistance Program