Quality Improvement Infection Control Nurse

Quality Improvement Infection Control Nurse

USPI Northwest Surgery Center Red Oak is seeking a motivated Quality Improvement Infection Control Nurse to join our team. We have 5 operating rooms and 2 treatment rooms, performing outpatient surgical procedures across several specialties. This position proactively develops and supports performance improvement processes in compliance with regulatory, federal, and state requirements. The PI Coordinator will manage all functions related to performance improvement, may be delegated additional responsibilities or special assignments, and will also manage the Infection Control program.

• Develop and implement a performance improvement plan that meets regulatory requirements.
• Modify the Performance Improvement Plan as needed to maintain regulatory compliance and current standard of practice.
• Annually review the effectiveness of the Performance Improvement Plan in writing and submit the annual review and any recommendations for improvement to committees including the MEC and GB.
• Ensure EDGE™ audits are assigned, educated and entered into the system per the EDGE™ calendar requirements located on USPInSite’s EDGE tab.
• Develop reports for EGDE™ audits and Risk and Patient Relations entries as well as other audits performed at the facility so that the data can be analyzed and acted upon as needed.
• Assist in the aggregation and analysis of data and report findings to the appropriate committees.
• Ensure the minutes of meetings reflect the PI reports discussed and include attachments.
• Assist in continuous quality improvement processes as the facilitator/coach.
• Ensure all necessary follow-up/action items are completed, reported, and documented in order to close the quality loop.
• Perform Root Cause Analysis (RCA) as needed (Sentinel Event) and report findings to appropriate committees and to the Governing Body.
• Ensure all RCAs performed contain the necessary follow-up/action items, reporting, and documentation in order to prevent future occurrences.
• Perform Failure Mode Effect Analysis every 18 months on a high risk, high volume/low volume, problem-prone process and implement all required action items.
• Able to work as a team member.
• Serve as recording secretary for the performance improvement section of meeting minutes.
• Manage required regulatory reporting including but not limited to ASCQC measures and improve compliance with these measures.
• Manage the regulatory compliance and survey preparedness by implementing a continuous readiness model of compliance.

• Provide employee education for the prevention of infection.
• Provide Infection Control post-operative surveillance, data collection, assessment, measurement, and report findings to the Quality Assessment Committee.
• Provide surveillance and assessment of infection control practices related to Standard Precautions, Transmission Precautions, and Exposure Control.
• Provide facility surveillance related to infection control.
• Serve as the facility resource person for infection control.
• Provide review of the appropriateness of agents used for disinfecting and antisepsis.
• Report activities related to infection control to the Quality Assessment Committee.
• Review the Infection Control policies and guidelines for program scope, objectives, performance, and effectiveness at least annually and provide recommendations to the PI committee for revision/approval.
• Assist with employee Infection Control orientation and in-services.
• Follow the Center's professional conduct and dress code policy.
• Maintain patient, physician, and employee privacy and confidentiality per policy.
• Act in accordance with the vision, mission, and business philosophy of the Center.
• Assist with other responsibilities of the center as deemed necessary by management.

• Graduate of an accredited RN School of Nursing.
• Currently hold RN licenses in the state.
• BLS certification.
• Completed orientation program, annual update, and other educational offerings related to Infection Control.
• Possess the knowledge, skills, and abilities of a Staff Nurse.
• Specific training in Employee Health supplied by the organization.
• Good command of the English language, both verbal and written.
• Able to work well with physicians, employees, patients, and others.

USPI complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

Entry level

Full-time

Health Care Provider