Clinical Quality & Education Specialist

Essential Duties and Responsibilities:

• Quality Assurance

  • Coordinate the ASC Quality Assessment and Performance Improvement (QAPI) Program.
  • Monitor, analyze, and trend quality indicators and performance metrics.
  • Conduct routine medical record, clinical, and documentation audits.
  • Conduct routine quality and compliance rounds at assigned ASCs.
  • Develop audit tools, dashboards, and tracking reports to support ASC operations.
  • Prepare quality reports for the Quality Committee and Governing Board.
  • Monitor completion of corrective action plans and performance improvement projects.
  • Investigate quality concerns and assist Regional Clinical Directors with corrective action plans.
  • Assist management and other key stakeholders in identifying opportunities for clinical and operational improvement.
  • Provide guidance regarding CMS Conditions for Coverage, accreditation standards, infection prevention, and patient safety requirements.
  • Coordinate regulatory readiness activities and assist centers with accreditation and licensing surveys.
  • Identify education opportunities through routine audits and quality rounds.
  • Partner with management and other key stakeholders to implement targeted improvement plans and staff education.
  • Assist with competency remediation and follow-up when deficiencies are identified through audits, surveys, or event investigations.

• Infection Prevention

  • Conduct annual Infection Prevention Risk Assessments.
  • Perform infection surveillance, including surgical site infection (SSI) tracking.
  • Conduct infection prevention rounds and compliance audits.
  • Monitor sterilization and high-level disinfection processes.
  • Coordinate required NHSN and regulatory reporting, as applicable.
  • Provide infection prevention education and annual competency support.
  • Monitor compliance with CDC, APIC, AORN, CMS, and Joint Commission infection prevention standards.

• Risk Management

  • Investigate patient safety events, adverse events, and incident reports.
  • Coordinate Root Cause Analyses (RCAs) and corrective action plans.
  • Track and trend patient safety events to identify recurring opportunities for improvement.
  • Assist with patient complaint investigations, as appropriate.
  • Monitor completion and effectiveness of corrective actions following incident investigations.
  • Prepare risk management reports and trending for leadership and Quality Committee review.

• Clinical Education & Competency Support

  • Coordinate and support education related to quality improvement, patient safety, infection prevention, and regulatory compliance.
  • Develop educational resources and competency tools based on audit findings, regulatory updates, accreditation standards, and identified performance gaps.
  • Collaborate with management and other key stakeholders to provide focused education following quality audits, incident investigations, and survey findings.
  • Assist with annual competency validation related to infection prevention, sterilization, moderate sedation, patient safety, and other regulatory requirements.
  • Support orientation and onboarding of Lead RNs, ASC leadership, and clinical staff related to quality initiatives, QAPI, regulatory compliance, and accreditation standards.
  • Serve as a resource to physicians and clinical staff regarding quality improvement initiatives, regulatory compliance, evidence-based practice, and patient safety.
• Checks and responds to work e-mail on a regular basis throughout the workday.
• Participates in and completes all required trainings and in-services.
• Performs other duties as assigned.

Minimum Qualifications: