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Position Summary The Quality, Compliance, and Infection Prevention Coordinator (RN) supports the Nurse/Quality Manager in implementing, monitoring, documenting, and maintaining Salem Endoscopy Center's Quality Assessment and Performance Improvement (QAPI), Infection prevention, employee and patient safety, and emergency preparedness programs. The Coordinator performs assigned audits, surveillance, education, committee support, follow-up, and regulatory-readiness activities using protected administrative time. The role identifies risks, maintain reliable evidence of program activity, and promptly escalates significant findings to the Manager. Essential Responsibilities Clinical Coverage Serve as a staff RN when assigned to support call-outs, vacation coverage, temporary staffing shortages, or other operational needs. Maintain required clinical competencies and perform staff RN duties in accordance with facility policies, scope of practice, and assigned patient-care responsibilities. Communicate promptly with the Quality Manager when clinical coverage effects scheduled administrative work, audits, meetings, or required reporting deadlines. Quality and QAPI Collect, validate, analyze, trend, and summarize date for assigned quality indicators, performance-improvement studies, patient outcomes, and operational responsibilities. Maintain QAPI project files, action plans, audit tools, dashboards, meeting materials, minutes, and evidence of follow-up through completion. Conduct assigned documentation, medication, clinical-practice, patient-safety, and process audits; identify patterns, gaps, and over-due actions. Assist the Quality Manager with policy and procedure review by reserarching current requirements, identify needed revisions, tracking review dates, and preparing drafts for Quality Manager and governing-body approval. Support complaint, grievance, transfer, peer-review, and other quality-related tracking when specifically assigned, while maintaining required confidentiality. Infection Prevention Conduct Infection surveillance, including post-procedure infection follow-up, trend analysis, and assigned internal or regulatory reporting. Perform and document audits or observations related to hand hygiene, personal protective equipment, environmental cleaning, injection safety, medication practices, point-of-care testing, and other infection-preventative priorities. Monitor endoscope reprocessing practices and documentation for alignment with facility policy, manufacturer instructions for use, and applicable evidence-based guidance; promptly escalate unsafe practices or process failures. Assist with infection-related investigations, exposure follow-up, corrective actions, staff educations, and monitoring for sustained compliance. Prepare Infection Control Committee materials and assist with the annual infection prevention plan, risk assessment, goals evaluation, and required reports. Maintain role-appropriated infection prevention education and competency and serve as an accessible resource to staff within the limits of assigned authority. Safety and Emergency Preparedness Coordinates Safety Committee meetings and maintain agendas, minutes, attendance, action items, and supporting records. Complete assigned facility safety rounds, environmental audits, hazard assessments, and follow-up; track identified concerns through resolution or escalation. Assist with occupational safety activities, including exposure-control, sharps-safety, respiratory-protection, injury-prevention, and required log or record review, as assigned. Coordinate and document required drills or actual events. Immediately report serious hazards, regulatory concerns, unsafe conditions, or threats to patient or employee safety to the Quality Manager and other designated leaders. Education, Competency, and Survey Readiness Develop, coordinate, or provide assigned education and competency observations when qualified and formally assigned; maintain attendance and completion records. Provide timely feedback and corrective educations with the scope of the role and refer performance or disciplinary concerns to the Quality Manager. Maintain organized survey-ready evidence of program activity and identify missing, incomplete, or over-due requirements. Support preparation for AAAHC, CMS, OHA, OSHA, and other applicable reviews, inspections, or surveys, including document collection and corrective-action follow-up. Maintain and provide routine status updates, findings, risks, and barriers to the Quality Manager. Credentialing and Human Resources Support Coordinate and maintain credentialing, license, certification, and other required qualification documentation for SEC staff and CRNA's; track expirations, obtain missing information, and prepare files for review and approval. Communicate credentialing deficiencies or upcoming expirations to the Quality Manager or Human Resources, assist with limited fact gathering, document collection, interviews, or other administrative support related to an employee concern or investigation while maintaining confidentiality and objectivity. Role Boundaries and Accountability The Coordinator works under the direction of the Nurse/Quality Manager, who retains program oversight, final approval, prioritization, personnel management, and communication wit the Medical Director, governing body, and external agencies unless specifically delegated. The Coordinator may recommend corrective action and workflow changes but does not independently establish policy, impose discipline, or make final staffing or operational decisions. Protected administrative time is required for the program responsibilities in this description. Administrative work is not expected after a full clinical floor shift. The Coordinator may be scheduled for reassigned as a staff RN for call-outs, vacation coverage, staffing shortages, or other operational needs. When clinical coverage replaces protected administrative time, the Quality Manager will reassess priorities, regulatory deadlines, and completion dates. The Coordinator does not independently impose discipline, make disciplinary decisions, or deliver formal employee discipline. These responsibilities remain with the Quality Manager and Human Resources. Quality Manager Coverage In the Quality Manager's absence, serves as the designated departmental lead and primary point of contact for routine operational matters. Provides day-to-day guidance to staff, supports departmental operations, and escalates matters requiring higher-level approval in accordance with established policies and delegated authority. Minimum Qualifications Current, unencumbered Oregon RN license and required clinical certifications. Relevant ambulatory surgery, endoscopy, infection prevention, quality, patient safety, or emergency-preparedness experience preferred. Documented role-appropriate infection prevention education and competency; willingness to complete additional education required by the facility or applicable regulations. Ability to conduct audits, analyze and present data, prepare reports, educate staff, manage multiple deadlines, and maintain accurate confidential records. Working knowledge of regulatory and accreditation requirements applicable to an ambulatory surgery center preferred. Performance Expectations Assigned recurring responsibilities are completed according to the approved schedule, with barriers communicated before deadlines when possible. Documentation is accurate, organized, current, confidential, and readily retrievable. Significant findings and safety risks are escalated promptly and through the appropriate chain of command. Corrective actions and follow-up monitoring are tracked through completion, with unresolved concerns reported to the Quality Manager. Communication with staff and leaders is objective, respectful, and with-in the authority of the role.

Pay:

$40.00 - $60.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) 401(k) matching Dental insurance Employee assistance program Health insurance Health savings account Life insurance Paid time off Referral program Retirement plan Vision insurance

Work Location:

In person