Quality Registered Nurse RN

Surgery Partners, Inc•Altoona, WI

About The Position

The Quality Registered Nurse (RN) is responsible for leading and overseeing key programs that support clinical excellence, patient safety, and regulatory compliance. This role oversees quality improvement initiatives, infection prevention and control, staff education, and employee health services. The Quality RN monitors performance data, ensures adherence to accreditation and regulatory standards, and collaborates with interdisciplinary teams to promote a culture of safety, continuous improvement, and high-quality patient care.

Requirements

Demonstrates eligibility for employment in the U.S.
Bachelor’s degree in nursing (BSN) from an accredited nursing program required
Current RN licensure in the State of Wisconsin required
BLS certification is required upon hire
Must obtain ACLS and PALS certification within twelve (12) months of hire
Three or more years of health care experience is required
Certified Professional in Healthcare Quality (CPHQ) required within 36 months of hire date
Must possess a cell phone that interfaces with the organization’s secure messaging system
Medical terminology
Electronic Medical Records (EMR) systems
Performance Improvement
Quality assurance and accreditation standards
Understanding of HIPAA regulations, patient confidentiality laws and patient rights
Effective English communication in verbal and written format
Quality work including attention to detail and accuracy
Advanced computer proficiency, including experience with Microsoft Xcel
Carry out customer service standards
Prioritize tasks effectively through managing workload based on urgency and importance
Capacity to work independently and as part of a multidisciplinary team
Continuously learn and improve through staying up to date on job specific trends, policies and new technologies
Successfully demonstrate organization-wide performance review competencies

Responsibilities

Develop, implement, monitor, and maintain the organization’s Quality Assessment and Improvement Plan, programs, and initiatives
Collect, analyze, and report quality and performance data; identify trends and communicate findings to staff, leadership, and providers
Ensure compliance with regulatory requirements
Lead survey readiness and accreditation activities, including regular rounding.
Lead quality and performance improvement initiatives, including planning, implementation, monitoring, and alignment with organizational goals
Collaborate with leaders and departments to maintain and advance quality improvement projects and promote a culture of safety and accountability
Serve as a clinical and quality resource; educate and coach staff on quality measures, regulatory expectations, and best practices
Support infection prevention, QAPI, and organizational education initiatives, including training and annual program development
Assist in patient relations by investigating grievances and helping resolve them through effective management
Serve as the Risk Manager by identifying, assessing, and mitigating potential risks to patient safety and quality of care
Engage with vendors and providers to support implementation of new quality-related programs and initiatives
Lead rounding, committees, and interdisciplinary collaboration to identify and drive improvement opportunities
Chair and participate in Performance Improvement and Safety Committee
Manage development and review processes for policies
Serves as a member of the Internal Review Board and the Medical Executive Committee
Use the organization's secure messaging platform in accordance with departmental protocols, including timely receipt and responses to communications
Serve as a resource for staff, leadership, and providers, promoting evidence-based infection prevention practices and standards
Develop, implement, monitor, and maintain the organization’s infection prevention and control plan, programs, and initiatives
Serve on organizational committees related to quality, safety, and infection control
Ensure compliance with local, state, and federal infection control regulations
Collect, analyze, and report infection data in a timely manner to identify trends and initiate interventions as needed
Collect and monitor 30- and 90-day infection and complication surveillance data; collaborate with surgeons and staff to investigate and respond to identified issues
Conduct routine rounding to assess infection control practices and promote survey readiness throughout the organization
Ensure infection reporting deadlines are met
Educate staff, providers, and leadership on infection prevention protocols and regulatory updates
Support the organizations preparedness and compliance during public health events or emerging infection threats
Coordinate, develop, and deliver comprehensive education programs for clinical and non-clinical staff across the organization
Oversee new hire orientation, onboarding, and ongoing competency validation for staff
Plan and implement organization-wide, unit-based, and role-specific education, including annual training and certifications (BLS, ACLS, PALS)
Ensure compliance with regulatory requirements through effective education, documentation, and tracking of training completion
Develop and manage computer-based learning modules and education records
Collaborate with leadership and department teams to assess, design, and meet ongoing education needs
Facilitate education-related committees, skills fairs, and training initiatives to support clinical competency and patient safety
Provide real-time education and support through rounding, staff meetings, and on-demand training
Monitor, analyze, and report education metrics and outcomes to support organizational goals and compliance
Oversee education and drills for emergency situations
Serve as a subject matter expert and resource on employee health best practices and infection prevention
Develop, implement, document, and continuously monitor the Employee Health Program in alignment with regulatory requirements and organizational goals
Ensure compliance with local, state, and federal regulations through collaboration and communication with organizational leadership
Collect, analyze, and report employee health data in a timely and accurate manner
Conduct health assessments and screenings for new hires, ensuring compliance with immunization and health status requirements
Coordinate and oversee the provision of employee health services, including screenings, follow-ups, and wellness initiatives
Assess, treat, and follow up on bloodborne pathogen exposures and perform communicable disease exposure tracking
Participate in and manage preventative screening and immunization programs
Monitor trends in employee illness and injury and develop strategies to reduce workplace-acquired conditions
Maintain accurate and confidential employee and non-employee health records
Lead the planning and execution of the seasonal influenza and other immunization programs, including tracking, follow-up, and reporting
Perform other duties as assigned