2000000313 Requisition #

Responsibility for developing and implementing patient safety initiatives, assuring success of continuous quality enhancement initiatives inter-and intra- departmentally and Oversees an effective infection control/prevention program. This role Responsible for the appropriate use of quality tools (root cause analysis, failure mode effects analysis, histograms, fish bones, cause maps statistical process control and other statistics) to help problem solve and benchmark appropriately. Assures compliance with regulatory standards and Ensures they are continually upheld.  Will be responsible for the planning, development, implementation administration, evaluation and continual enhancement of policies, procedures and practices for each functional area.


1. Develop, implement and continually enhance programs to proactively assess and monitor compliance by all departments and services with all applicable regulatory requirements.
2. Develop and facilitate multidisciplinary surveys of all departments and services on a random basis to monitor and assess for continued compliance.
3. Coordinate and facilitate any announced or unannounced surveys.
4. Respond to requests by the leadership team, executives for follow up on letters of complaint from regulatory or accrediting agencies.
 1. Develop, implement and continually enhance programs to proactively assess, monitor and continually enhance quality standards.
 2. Ensure that policies and procedures are current and meet all current laws, regulations and standards of care; monitor dates of review and revision; revise as appropriate.
 3. Establish and continually enhance the Quality Council, serving as leader; serve as a member of quality committees as required.
 4. Coordinate environment of care rounds.
 5. Serve as the liaison to the Chief Quality Officer (CQO).

 Infection Control
1. Collaborate with the Infection Control Specialist and appropriate Health System staff to develop and implement infection control programs and practices.
2. Assist the Infection Control department in reviewing departmental and infection control policies, assisting in the development and revision to ensure that current practice meets professional and regulatory standards.
Maintain current knowledge and expertise through professional organizations and relationships with others in area of practice.

1. Develop, implement and appropriately manage budgets to ensure necessary funding for operational and capital needs.
2. Pursue creative strategies to lower costs while maintaining or enhancing quality




Education and Licensure

*Master's Degree
*Registered Nurse (RN)

Minimum Experience
*Minimun of seven (7) years experience in the discipline and five (5) years leadership experience

Minimum Knowledge, Skills, and Abilities
Working knowledge of applicable laws, regulations and accreditation standards are a must. Database and statistical software packages.

About Us

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Chances are, you’re here because you’re looking for a career offering greater opportunity, challenge and fulfillment. We’re confident you’ll find all three at CHI. As one of the nation’s largest nonprofit health systems, we offer a wealth of careers across more than 101 hospitals in 18 states. Our faith-based health system welcomes you to share in our mission of building healthier communities, whether as a surgeon in the operating room or an administrator in a conference room. When you work in a supportive environment with like-minded professionals, wonderful things happen. Learn More

Equal Opportunity Employment

Consistent with our Core Values, Catholic Health Initiatives employers are EEO/AA/M/F/Vets/Disabled Employers. Qualified applications will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identification, protected veteran status, disability or any other legally protected characteristic

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