Director of Nursing

DIRECTOR OF NURSING – AMBULATORY SURGERY CENTER

Position Title:

Director of Nursing (DON)

Department:
Clinical Operations

Reports To:

Administrator

Supervises:
Registered Nurses, LVNs/LPNs, Surgical Technologists, and other assigned clinical personnel

Employment Status:
Exempt / Full-Time

Facility:
Ambulatory Surgery Center

The Director of Nursing (DON) is responsible for the leadership, management, coordination, and oversight of nursing and clinical services within the Ambulatory Surgery Center (ASC). The DON ensures that safe, high-quality patient care is provided in accordance with facility policies, medical staff requirements, applicable federal and state regulations, accreditation standards, and accepted standards of professional nursing practice.

The DON works collaboratively with the Administrator, Medical Director, medical staff, anesthesia providers, and facility personnel to maintain a safe, efficient, patient-centered surgical environment.

• Direct and oversee day-to-day nursing and clinical operations of the ASC.
• Ensure appropriate nursing care throughout the perioperative process, including pre-operative, intra-operative, and post-anesthesia recovery services.
• Promote and maintain a culture of patient safety and regulatory compliance.
• Ensure appropriate implementation of physician orders and established clinical protocols.
• Monitor patient care practices and intervene when patient safety or quality concerns are identified.
• Ensure emergency equipment, medications, supplies, and clinical resources are available and maintained appropriately.
• Participate in emergency preparedness activities, drills, and staff education.
• Ensure appropriate infection prevention practices are consistently followed.

• Provide leadership, supervision, coaching, and direction to clinical staff.
• Participate in recruitment, interviewing, selection, orientation, and onboarding of clinical personnel.
• Develop clinical staffing schedules based on patient volume, procedure complexity, staff competency, and operational requirements.
• Verify that clinical staff maintain required licenses, certifications, competencies, and training.
• Conduct and document initial and ongoing staff competency assessments.
• Identify performance deficiencies and implement education, counseling, corrective action, or performance improvement measures as appropriate.
• Conduct or participate in employee performance evaluations.
• Promote teamwork, accountability, professionalism, effective communication, and a positive workplace culture.
• Ensure appropriate staffing and skill mix for scheduled procedures.

• Assist the Administrator and Medical Director in maintaining compliance with applicable ASC requirements, including CMS Conditions for Coverage, state licensing requirements, OSHA requirements, infection prevention standards, and applicable accreditation standards.
• Maintain readiness for regulatory and accreditation surveys.
• Participate in survey preparation, surveys, plans of correction, and follow-up activities.
• Ensure required clinical policies and procedures are implemented and followed.
• Assist with review and periodic revision of nursing and clinical policies.
• Ensure required clinical documentation, logs, inspections, and records are properly maintained.
• Participate in Governing Board and Medical Executive Committee activities when requested or required.

• Participate in the facility's Quality Assessment and Performance Improvement (QAPI) program.
• Identify opportunities for clinical performance improvement and patient safety initiatives.
• Assist with development, implementation, monitoring, and reporting of quality improvement projects.
• Monitor clinical quality indicators, patient outcomes, medication errors, adverse events, infections, transfers, incidents, and other quality measures.
• Participate in root-cause analysis and corrective-action activities when appropriate.
• Report significant clinical or patient safety concerns promptly to the Administrator and Medical Director.

• Work collaboratively with the designated Infection Preventionist to maintain an effective infection prevention and control program.
• Ensure compliance with hand hygiene, sterilization, disinfection, environmental cleaning, safe injection practices, and other infection prevention requirements.
• Monitor staff…