Quality Assurance Nurse (45837)

Under general supervision of the Chief Quality Officer the Quality Assurance Nurse serves a critical role in advancing patient care quality while ensuring regulatory and accreditation compliance across the facility. This position combines clinical expertise, data analysis, and process improvement methodologies to enhance patient outcomes, reduce risk, and maintain adherence to tribal, federal, and accreditation standards. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Lead and coordinate quality improvement projects to enhance clinical outcomes and patient safety.
• Utilize data analysis to identify care gaps, trends, and opportunities for process optimization.
• Implement PDSA cycles (Plan-Do-Study-Act) and other QI methodologies to address performance gaps.
• Develop and monitor performance metrics aligned with GPRA, CMS, and IHS reporting requirements.
• Collaborate with clinical staff to design and implement evidence-based interventions.
• Provide staff education on best practices and clinical performance initiatives.
• Conduct ongoing compliance audits of clinical documentation, policies, and procedures.
• Assures hospital compliance with regulations and standards using regular surveys and centralized tracking.
• Monitor adherence to tribal, federal, and accreditation standards, including The Joint Commission and CMS Conditions of Participation.
• Prepare and coordinate facility readiness for surveys, inspections, and internal reviews.
• Facilitate corrective action plans and follow-up for identified compliance gaps.
• Supports the implementation of clinical guidelines that may include, but is not limited to, developing/obtaining appropriate education material for each nursing department’s quality process model and developing new measures/indicators that will improve the overall quality of care and safety, which we provide to our patients.
• May act as a liaison with regulatory bodies and internal departments to ensure continuous compliance.
• Conducts Root Cause Analysis (RCA) of sentinel events and reports findings to the Chief Quality Officer and the executive team.
• Participates in the development and implementation of long and short-term goals as well as policies for clinical quality and safety.
• Combine quality improvement initiatives with compliance monitoring to drive patient-centered outcomes while mitigating risk.
• Report findings, recommendations, and performance metrics to the Chief Quality Officer in a timely manner.
• Participate in interdepartmental committees focused on quality, safety, and compliance.
• Support the development and revision of policies and procedures to align with best practices and regulatory standards.
• Plans and adjusts work schedules and operations to meet established objectives, priorities, deadlines and standards of care to ensure a seamless workflow.
• Provides ongoing monitoring and evaluation of the effectiveness of hospital performance improvement and risk management programs.
• Works collaboratively with the Infection Control Program and the Safety Committee to identify and correct unsafe conditions and work practices.
• Reports unusual or questionable situations to the Chief Quality Officer and/or Leadership.
• Provides feedback to departments and front-line staff to facilitate quality/safety implementation.
• Assists, promotes, and supports compliance with established CMS standards.
• Completes all yearly CMS required training by the indicated due dates.
• Requires completion of tasks or duties assigned by a supervisor.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.

Minimum Qualifications:

Requires current and unrestricted Registered Nurse (RN) license. Bachelor’s degree in Nursing required, Master’s in Nursing, Public Health or Health Administration preferred. Minimum of three (3) years of clinical experience preferable in Acute Care, Urgent Care or Emergency Department. Requires experience in compliance monitoring, auditing and regulatory standards of CMS, TJC, IHS, etc. Prefer a certification in Healthcare Quality (CPHQ) and preference of experience working in an IHS or 638 facility. Bilingual skills in English and Navajo language preferred.  Must maintain a valid unrestricted and insurable driver’s license.  Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).

Knowledge, Skills, Ability

• Knowledge of strong work ethics in the workplace.
• Knowledge of basic application of confidentiality.
• Knowledge of duties and responsibilities of the position.
• Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
• Knowledge of nursing practice in a clinical setting to aide in quality initiatives.
• Knowledge of quality improvement methodologies.
• Knowledge of regulatory standards and compliance requirements for CMS, TJC, IHS, GPRA and UDS reporting requirements.
• Ability to interpret clinical and compliance data to identify gaps and trends.
• Ability to be dependable in attendance and job performance.
• Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
• Ability to accept and learn from feedback.
• Ability to track, report, and maintain performance metrics for quality and compliance programs.
• Ability to conduct audits and compliance monitoring to ensure adherence to standards.
• Ability to effectively communicate both in written and verbal.
• Ability to provide exemplary customer service at all times.
• Ability to work in both clinical and office environment at all WIHCC, Inc. locations.
• Ability to interact positively with others and possess great interpersonal skills.
• Ability to multitask and perform well under pressure.
• Ability to have self-confidence.
• Ability to be a great team player.
• Ability to accept and learn from supervisor/peer critique.
• Ability to be flexible and adaptable to the changing needs of the organization.

Physical Demands:

While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.

Work Environment:

Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.  

As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants.  If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.