Position Title:              Quality and Infection Control Nurse 

Supervisor:                  Senior Director of Clinical Operations and HR

Supervises:                  N/A      

Mission and Values: 

In the performance of one’s job, the employee reflects the Mission by participating in the provision of convenient, cost-effective, quality surgical care.

Values:                  Confidentiality

                               Quality

                                Teamwork

                                Trust

                                Respect

Job Summary:

The Quality Nurse will advocate for both the patient and YSC. Ultimately, the goal is to optimize patient outcomes with cost-effective care. As a liaison between the patient, provider, and payer, the Quality Nurse will facilitate an in-depth analysis of current nursing practices. 

Duties and Responsibilities:

• Collects, analyzes, and presents quality data at quarterly QAPI meetings which are facilitated by the Quality nurse 
• Assists YSC clinical staff with delegation and follow-through on QI Projects 
• Develop, implement, and maintain quality, infection control and risk management policies and procedures in compliance with regulatory agencies. 
• Monitor compliance with quality, infection control, and risk management policies and procedures
• Monitors, analyzes, and reports OAS CAHPS Patient Satisfaction survey results 
• Assist with the planning and organization of YSC Emergency preparedness 
• Maintain Life Safety Binder, ensure all documentation is readily available and current 
• Complete Annual Contracted Services Evaluation 
• Complete Annual OSHA Safety Device Review 
• Complete Annual Radiology Safety
• In conjunction with the Medical Director, coordinates the pharmaceutical program. This includes: ordering pharmaceuticals, DEA licensure, annual inventory
• Maintain Pharmacy binder, ensure proper documentation is readily available and current 
• Complete Annual Infection Control Risk Assessment & Review YSC Infection Control Plan 
• Maintain records of infections investigate outbreaks of infections and implement corrective action
• Perform surveillance of nosocomial infections
• Completes Annual TB Risk Assessment and submits checklist to the state 
• Educate YSC staff and providers on quality trends, quality initiatives, and infection control practices 
• Actively participate on the YSC Education Committee 
• Performs other duties as assigned

Physical Demands:

While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear.  The employee is frequently required to walk.  The employee is occasionally required to sit, climb, balance, stoop, or crawl. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, and the ability to adjust focus. Prolonged periods of sitting at a desk and working on a computer. Must be able to lift 50 pounds at times. Normal hospital environment with exposure to chemical odors, cleaning solvents, and other hazardous materials. Exposure to possible injury when working with electrical equipment and lasers which requires care and following proper safety procedures.

Sedentary                           Primarily sitting/lifting 10 lbs maximum

Light                                  Lifting 20 lbs maximum with frequent lifting/carrying up to 10 lbs

Medium          X                Lifting 50 lbs maximum with frequent lifting/carrying up to 20 lbs

Heavy                                Lifting 100 lbs maximum with frequent lifting/carrying up to 50 lbs

Very Heavy                        Lifting over 100 lbs with frequent lifting/carrying up to 50 lbs

Bloodborne Pathogens

Based on the OSHA guidelines for protection against occupational exposure to Hepatitis and HIV, this position is described as Category I.  This means that this position has minimal or no exposure to blood and body fluids.  Policies are in place for Universal Precautions identifying exposure risks and appropriate barrier protection.

The above is intended to describe the general content and requirements for the performance of this position.  It is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.

Education, Experience, Licensure/Certification Requirements:

• Graduate of an accredited school of nursing
• Current RN licensure in the state of Montana 
• Current CPR certification 
• Preferred experience with Quality and Infection Control in the perioperative setting 
• Preferred certification as a Certified Infection Control Nurse or willing to attain within two years