Director of Nursing - Pain Management ASC

POSITION SUMMARY

The Director of Nursing (DON) is responsible for the overall planning, organization, direction, and evaluation of nursing services at our Arizona-licensed Ambulatory Care Surgery Center. This is a dual-role leadership position: the DON simultaneously serves as the facility's designated Infection Control Officer (ICO), providing oversight of the infection prevention program in compliance with Arizona Department of Health Services (ADHS), Centers for Medicare & Medicaid Services (CMS) Conditions for Coverage, and The Joint Commission (TJC) standards where applicable.

The DON/ICO reports directly to the Administrator and is a voting member of the Quality Assurance and Performance Improvement (QAPI) committee. This individual is expected to foster a culture of clinical excellence, patient safety, and regulatory compliance while serving as a professional and ethical role model for nursing and clinical support staff.

KEY RESPONSIBILITIES — NURSING LEADERSHIP

• Provide strategic and operational leadership for all nursing and clinical staff, including pre-op, intra-op, and PACU/post-op units.
• Develop, implement, and evaluate nursing policies, procedures, and standards of care in alignment with ACS regulatory requirements.
• Oversee nursing staffing, scheduling, and competency validation to ensure appropriate staffing ratios and skill mix at all times.
• Lead recruitment, onboarding, performance evaluation, disciplinary actions, and ongoing professional development for nursing personnel.
• Conduct and document quarterly and annual nursing performance reviews in accordance with facility HR policy.
• Serve as the primary resource for clinical problem-solving, patient safety events, and nursing practice issues.
• Collaborate with surgeons, anesthesiologists, and the surgical team to optimize perioperative patient care and throughput.
• Oversee administration of conscious sedation protocols, ensuring compliance with ASPAN and AORN guidelines.
• Ensure proper maintenance of the medication management program, including controlled substance reconciliation in partnership with the pharmacy consultant.

KEY RESPONSIBILITIES — INFECTION CONTROL OFFICER

As the designated Infection Control Officer, the DON/ICO develops and maintains a comprehensive infection prevention and control program meeting ADHS, CMS, and CDC standards for ambulatory surgical settings.

• Design, implement, and continuously evaluate the facility-wide Infection Prevention & Control (IP&C) Plan.
• Monitor and enforce compliance with standard precautions, transmission-based precautions, and surgical asepsis protocols throughout all clinical areas.
• Conduct routine environmental rounds to assess hand hygiene compliance, sterilization/high-level disinfection practices, and instrument reprocessing integrity.
• Oversee sterile processing functions; ensure all staff performing sterilization are trained per IAHCSMM or CBSPD standards.
• Track, investigate, and analyze healthcare-associated infections (HAIs) and surgical site infections (SSIs); implement evidence-based corrective actions.
• Maintain surveillance data and trend analysis reports; present findings to the QAPI committee no less than quarterly.
• Serve as the facility liaison to ADHS and public health authorities regarding reportable disease/infection incidents.
• Ensure proper handling, storage, and disposal of biohazardous and regulated medical waste per OSHA and Arizona DEQ requirements.
• Develop and deliver annual IP&C education for all clinical and non-clinical staff; maintain training records.
• Stay current on CDC guidelines, APIC recommendations, and emerging infectious disease threats; update policies accordingly.

REPORTING & COMPLIANCE RESPONSIBILITIES

The DON/ICO holds direct accountability for the following reporting functions:

• Submit written Infection Control surveillance and trend reports to the QAPI committee on a quarterly basis and to the Governing Board annually.
• Prepare and present monthly nursing operations dashboards to the CEO/Administrator, covering staffing, incident data, quality indicators, and patient satisfaction trends.
• Document and report all sentinel events, near misses, and adverse patient outcomes to the Administrator and, as required, to ADHS within mandated timeframes.
• Maintain and report OSHA recordable injuries/illnesses; file required OSHA 300/300A logs in collaboration with HR.
• Complete and submit required CMS Conditions for Coverage self-assessment documentation during survey readiness activities.
• Coordinate all aspects of ADHS licensure surveys and CMS/accreditation body inspections; in conjunction with Administrator, prepare corrective action plans (CAPs) as indicated.
• Ensure timely reporting of communicable diseases to the Arizona Department of Health Services per A.R.S. Title 36 and A.A.C. R9-6 requirements.
• Maintain accurate and complete nursing policy and procedure manuals; review and update all clinical policies at minimum annually.
• Oversee documentation integrity for nursing records and ensure compliance with HIPAA privacy standards.

REQUIRED QUALIFICATIONS

• Current, active, unencumbered Registered Nurse (RN) license issued by the Arizona State Board of Nursing (AZ BON); compact license accepted if Arizona is declared primary state.
• Bachelor of Science in Nursing (BSN) required; Master of Science in Nursing (MSN) or healthcare administration degree strongly preferred.
• Minimum 3 years of progressive nursing leadership experience (charge nurse, supervisor, manager, or director level) in a surgical, perioperative, or ambulatory care environment.
• Demonstrated experience in infection prevention, including sterilization processes, HAI surveillance, and regulatory compliance — prior formal ICO/ICP role preferred.
• Proven history of managing regulatory surveys (ADHS, CMS, TJC, or AAAHC) and implementing effective corrective action plans.
• Experience with QAPI program management, data collection, and performance improvement methodologies (e.g., PDSA, Lean, Six Sigma).
• Strong understanding of CMS Conditions for Coverage for Ambulatory Surgical Centers (42 CFR Part 416).
• Proficiency in electronic health records (EHR) and clinical reporting platforms.
• Current BLS and ACLS certification.

PREFERRED QUALIFICATIONS & CERTIFICATIONS

• Familiarity with CMS, AAAHC or Joint Commission accreditation standards for ambulatory surgery centers.
• Experience with conscious sedation oversight, PACU nursing management, and OR charge nursing.

WORK ENVIRONMENT & PHYSICAL REQUIREMENTS

• Primary work environment is a licensed, single-specialty ambulatory care surgery center operating Thursdays with plans to increase case load and operating days; occasional extended hours required for regulatory preparation or operational needs.
• Exposure to bloodborne pathogens, infectious agents, and hazardous materials consistent with a surgical setting; PPE provided and required.
• Ability to stand, walk, and be on feet for extended periods; occasional lifting up to 50 lbs.
• Must be able to respond to clinical emergencies and remain composed under pressure.

COMPENSATION & BENEFITS

We offer a competitive compensation package commensurate with experience, including:

• Competitive base salary — commensurate with experience and qualifications
• Health and dental insurance
• Paid time off (PTO) and paid holidays
• Employer-sponsored continuing education and professional certification support
• Retirement plan with employer contribution

This position is subject to a background check, reference verification, and primary source licensure verification per Arizona state requirements. This job description is not intended to be an exhaustive list of duties. Other responsibilities may be assigned.

Equal Opportunity Employer | Arizona Licensed Ambulatory Care Surgery Center

Pay: $55.00 - $65.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off

Work Location: In person

Salary : $55 - $65