Position Summary

The Quality Nurse supports the hospital's Quality and Patient Safety Program by assisting with data collection, performance improvement initiatives, survey readiness, and compliance with regulatory and accreditation standards. This role collaborates with clinical and non-clinical departments to promote quality outcomes, ensure patient safety, and maintain continuous readiness for CIHQ/Joint Commission, CMS, and state surveys.

Essential Duties and Responsibilities

• Quality & Patient Safety * Monitor, track, and analyze quality and patient safety data, including core measures, infection prevention indicators, adverse events, and regulatory metrics. * Assist in developing, implementing, and evaluating performance improvement (PI) projects. * Support the hospital's peer review, mortality review, and quality council processes. * Educate staff and leadership on quality initiatives, best practices, and patient safety culture.
• Survey Readiness & Compliance * Maintain continuous readiness for CIHQ/Joint Commission, CMS, and state regulatory surveys. * Conduct tracer rounds, audits, and Environment of Care (EOC) rounds across clinical and non-clinical departments (nursing units, ancillary services, plant operations, EVS, security, dietary, etc.) to identify and correct compliance gaps. * Provide coaching and education to staff and leaders on regulatory requirements and best practices. * Assist with policy review and development to ensure alignment with accreditation and regulatory requirements. * Maintain records, logs, and documentation for survey readiness and accreditation activities.
• Data Management & Reporting * Collect, validate, and submit quality reporting data to CMS, NHSN, CIHQ, state agencies, and other regulatory bodies as required. * Provide reports to administration, quality council, and governing body as needed. * Generate and maintain quality dashboards and scorecards for leadership, quality committees, and the governing body. * Monitor hospital performance against benchmarks, patient safety goals, and regulatory indicators. * Participate in root cause analyses (RCA) and assist in action plan development and follow-up.

Knowledge, Skills, and Abilities

• Strong knowledge of CIHQ/Joint Commission standards, CMS Conditions of Participation, and state regulatory requirements.
• Working knowledge of Environment of Care (EOC) standards across both clinical and non-clinical departments.
• Strong background in quality reporting, NHSN surveillance, CMS measure submission, and regulatory data validation.
• Excellent organizational and time-management skills with attention to detail.
• Strong analytical skills with ability to interpret and present data to leadership.
• Proficiency with Microsoft Office Suite, NHSN portals, CMS QualityNet, and quality data systems.
• Effective communication and interpersonal skills for working with physicians, staff, and leadership.
• Ability to function independently while collaborating in a team environment.

Education & Experience

• Graduate of an accredited school of nursing; BSN preferred.
• Minimum 3 years of clinical nursing experience in an acute care hospital required.
• Experience in quality, patient safety, accreditation, or regulatory compliance preferred.
• Experience with CMS reporting requirements, NHSN surveillance and data entry, and hospital quality data reporting strongly preferred.
• Current, unrestricted RN license in the State of Texas (or compact state).
• Certified Professional in Healthcare Quality (CPHQ) preferred or obtained within 2 years of hire.