ASC Clinical Director

Surgery Partners•Bethlehem, PA

About The Position

The Clinical Director is an integral member of the management team, providing guidance and support for Performance Improvement, Certification, Accreditation, Patient Safety, Infection Prevention, and Employee Health activities across assigned freestanding Ambulatory Surgery Centers (ASCs). The role supports continuous improvement in CMS ASC Quality Measures, specialty quality measures, and patient experience outcomes, and serves as a resource to assigned ASCs for quality benchmarking, reporting, data analysis, and identifying trends and opportunities for improvement. The Clinical Director provides leadership and guidance for Infection Prevention and Employee Health, helping standardize processes and promote regulatory compliance across assigned facilities. In collaboration with Risk Management and Patient Safety teams, the role supports initiatives to strengthen patient safety, reduce organizational risk, and promote high-quality care across assigned ASCs. The position supports quality measurement and improvement, regulatory reporting, accreditation and certification activities, clinical content quality, patient experience strategies, infection prevention and employee health programs, and risk management and patient safety work. It also conducts assessments and mock surveys, develops facility-specific action plans, and prepares reports for facility leadership and governing boards.

Requirements

Bachelor's degree in Nursing, Healthcare, or a related healthcare field.
3–5 years of leadership experience in one or more areas such as Performance Improvement, Accreditation and Certification, Risk Management and Patient Safety, Infection Prevention, or Employee Health.
Strong knowledge of the healthcare industry and applicable local, state, and federal healthcare regulations.
Knowledge of quality and performance improvement activities in the ambulatory surgical setting.
Working knowledge of accreditation and certification standards and requirements.
Understanding of Infection Prevention, Employee Health, Risk Management, and Patient Safety principles.
Strong computer proficiency, including experience with databases and software applications needed to perform the role.
Demonstrated knowledge of process improvement methodologies, process analysis tools, and quality improvement principles.
Strong facilitation, problem-solving, and organizational skills.
Excellent verbal and written communication skills.
Ability to analyze trends, identify improvement opportunities, and communicate recommendations effectively to facility and organizational leadership.
Ability to collaborate effectively with clinical leaders, facility teams, and corporate partners across multiple locations.

Nice To Haves

Master's degree in Healthcare, Quality, Business Administration, or a related field.

Responsibilities

Ensure processes are in place to collect, measure, report, and improve quality measures required by CMS, state regulatory agencies, accreditation organizations, and other governing bodies.
Assist in developing specialty-specific benchmarking metrics and processes for measuring, reporting, and improving performance.
Support and participate in corporate task forces and performance improvement teams focused on quality initiatives.
Assist the VP of Clinical Operations (ASC) with materials for quarterly corporate Quality Council meetings.
Monitor changes in state, CMS, accreditation, and specialty-specific requirements and communicate relevant updates to assigned ASCs.
Support ASCs with required regulatory reporting, including QualityNet reporting.
Support implementation and quality review of clinical and evidence-based content, including documentation, physician order management, and plans of care when applicable.
Recommend processes to keep evidence-based clinical content current and accurate, and assist with drafting related policies.
Provide support and education about Patient Experience surveys and strategies to improve scores; review results at least quarterly for trends and improvement opportunities.
Assist the VP of Clinical Operations (ASC) with accreditation and certification activities, including mock surveys and plans of correction.
Conduct mock surveys at assigned ASCs, develop action plans for improvement areas, and follow up to promote sustained compliance.
Serve as a subject matter resource for Infection Prevention and Employee Health across assigned ASCs.
Ensure each ASC's Infection Prevention designee demonstrates and documents required competencies.
Orient and support staff newly assigned Infection Prevention and Employee Health responsibilities.
Ensure corporate template policies for Infection Prevention and Employee Health are disseminated and aligned with applicable state requirements.
Provide or coordinate on-site Infection Prevention and Employee Health support as needed.
Help develop tools, reports, and resources for Infection Prevention and Employee Health performance improvement initiatives.
Participate in recurring Infection Prevention and Employee Health networking calls and workgroups, and lead calls on topics specific to assigned state markets.
Assist facilities with regulatory reporting, including NHSN reporting and internal Surgical Site Infection investigations.
Collaborate with Risk Management and Patient Safety teams to help assigned ASCs minimize risk, improve patient safety, and reduce potential liabilities.
Conduct risk management assessments and develop facility-specific work plans based on findings; provide ongoing follow-up and support for identified opportunities.
Assist facilities with required state reporting within regulatory timeframes.
Review events in the event reporting system and guide facility risk management and leadership teams when additional information, follow-up, or revisions are needed.
Notify the ASC Clinical Operations team of Sentinel Events and assist with related investigations.
Assist assigned ASCs in developing credible Root Cause Analyses following significant incidents or adverse events.
Assist with preparation of the Quarterly Risk Management Report for facility Governing Board review.
Prepare reports for facility leadership and Risk Management containing written findings, identified or cited deficiencies, compliance recommendations, and recommended best practices.