Quality Improvement Infection Control Nurse

Responsibilities

Job   Date posted 11/10/2025

USPI Northwest Surgery Center Red Oak, is seeking a motivated Quality Improvement Infection Control Nurse to join our team. We have 5 ORs and 2 Treatment rooms. We perform outpatient surgical procedures in Colon and Rectal, ENT, Gastroenterology, General, Gynecology, Hand, Ophthalmology, Pain Management, Plastic, Podiatry, Urology.

This position exists to proactively develop and support the performance improvement process in compliance with regulatory, federal and state requirements. This position requires a person who is well organized and demonstrates a high degree of attention to detail. The PI Coordinator is required to manage all functions related to performance improvement at the facility. May be delegated additional responsibilities or special assignments.

You will also manage the Infection Control program. Demonstrates the primary goal of efficiently providing surgical services that exceed customer expectations and improve clinical and financial operations.

Essential

Job Duties and Responsibilities QI:

* Develops and implements a performance improvement plan that meets regulatory requirements.

* Modifies the Performance Improvement Plan as needed to maintain regulatory compliance and current standard of practice.

* Annually reviews the effectiveness of the Performance Improvement Plan in writing and submits the annual review and any recommendations for improvement to committees including the MEC and GB.

* Ensures EDGE audits are assigned, educated and entered into the system per the EDGE calendar requirements located on USPInSite's EDGE tab.

* Develops 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.

* Assists in the aggregation and analyzing of data and report's findings to the appropriate committees.

* Ensures the minutes of meetings reflect the PI reports discussed and includes attachments.

* Assists in continuous quality improvement processes as the facilitator / coach.

* Ensures all necessary follow-up / action items are completed, reported and documented in order to close the quality loop.

* Performs Root Cause Analysis (RCA) as needed (Sentinel Event) and report's findings to appropriate committees and to the Governing Body.

* Ensures all RCA's performed contain the necessary follow-up / action items, reporting and documentation in order to prevent future occurrences.

* Performs Failure Mode Effect Analysis every 18 months on a high risk, high volume / low volume, problem prone process and implements all of the required action items.

* Able to work as a team member.

* Serves as recording secretary for the performance improvement section of meeting minutes.

* Manages required regulatory reporting including but not limited to ASCQC measures and improves compliance with these measures.

* Manages the regulatory compliance and survey preparedness by implementing a continuous readiness model of compliance.

Essential

Job Duties and Responsibilities:

* Provides employee education for the prevention of infection.

* Provides Infection Control post-operative surveillance, data collection, assessment, measurement, and reports findings to the Quality Assessment Committee.

* Provides surveillance and assessment of infection control practices related to Standard Precautions, Transmission Precautions, and Exposure Control.

* Provides facility surveillance related to infection control.

* Serves as the facility resource person for infection control.

* Provides review for the appropriateness of agents used for disinfecting and antisepsis.

* Reports activities related to infection control to the Quality Assessment Committee.

* Reviews the Infection Control policies and guidelines for program scope, objectives, performance and effectiveness at least annually and provides recommendations to the PI committee for revision/approval.

* Assists with employee Infection Control orientation and in-services.

* Follows the Center's professional conduct and dress code policy.

* Maintains patient, physician, and employee privacy and confidentiality per policy.

* Acts in accordance with the vision, mission, and business philosophy of the Center.

* Assists with other responsibilities of center as deemed necessary by management

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Required Skills:

Qualifications:

* Graduate of an accredited RN School of Nursing.

* Currently RN licenses in the state.

* BLS

* Attends an orientation program, an annual update, and other educational offerings related to Infection Control.

* The knowledge, skills, and abilities of a Staff Nurse are required for this position.

* Employee Health - specific training is supplied.

* 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…