Job Description

Job Title: Quality Control Manager

Location:  Johnson County Hospital, Tecumseh, NE

Department:  Nursing

Reports To:  CEO

Position Summary:

To collect, review, and analyze patient data and lab reports to track infection rates. Create and update evidence-based infection prevention guidelines. Ensure the facility follows safety and reporting standards set by regulatory and accrediting bodies such as the CDC.

Manage the health, safety, and wellness of hospital employees to maintain a safe working environment through coordinating vaccination recommendations of the CDC, tracking employee illnesses and exposures.

Audit, monitor, review, and evaluate patient record documentation for healthcare standard accuracy, completeness, and compliance with CMS quality guidelines, Medicare Beneficiary Quality guidelines, electronic clinical quality measures and other quality reporting programs.

Plan, coordinate and implement required continuing education through yearly online courses, workshops, for hospital personnel.

Duties & Responsibilities:

Infection Prevention

Protect patients, staff, and visitors from the spread of infections or an infectious disease outbreak through surveillance, education, collecting, tracking, and reporting data.

• Lead a response to the spread of any communicable infectious disease outbreaks by collaborating with the local health department, Nebraska health department and CDC if needed.
• Educate employees on hand hygiene and personal protective equipment, and other infection prevention best practices.
• Collaborate with medical providers, lab, nursing, administration, public health departments, pharmacy to educate and implement evidence-based infection prevention protocols to align with best practice guidelines to improve compliance and patient outcomes.
• Track, analyze, report and evaluate all healthcare acquired infections that occur within the hospital to the- National Healthcare Safety Network (NHSN).
• Collaborate with antibiotic stewardship team to optimize antibiotic utilization.
• Facilitate and lead environmental assessments to provide a clean, and safe environment that is free of possible health and physical hazards for patients, visitors, and staff.
• Complete annual facility risk assessments for infection, TB, and legionella.
• Facilitate and lead water management committee meetings
• Complete any new construction infection control risk assessments.
• Facilitate water management committee meetings.
• Complete annual infection/antibiotic stewardship survey to NHSN.
• Review and revise infection control, employee health, in-service policies and procedures.
• Report to infection control committee quarterly summary of culture reports, healthcare acquired/community acquired infections, surgical site infections, reportable diseases, facility wide handwashing compliance, employee illnesses, and review of hospital quality measures.
• Offer qualified patients' vaccinations per CDC guidelines.

Employee Health

• Monitor employee trends in illnesses for possible outbreaks.
• Educate, promote, and provide vaccinations as recommended by the CDC for healthcare personnel and enter into the CDC database.
• Yearly mask fit test employees with direct patient contact.
• Ensure and monitor employee immunization status and immunity to MMR, Varicella, Hepatitis B, provision of immunizations, titers as needed and/or counseling in infections exposure incidents.

Employee Education

• Provide educational tools that facilitate professional competence and development through orientation and continuing education opportunities.
• Plan, coordinate and implement required continuing education through yearly online courses, workshops, videoconferences, in-services, and self-studies for hospital personnel.
• Maintain the facility learning management system.

Quality Manager

• Collect and Analyze quality metrics for continuous improvement for federal and state reporting
• Educate staff on any new quality metrics.
• Facilitate and lead monthly quality improvement committee meetings for all departments.
• Facilitate and coordinate annual CAH review with Bryan hospital.
• Monitor patient satisfaction survey responses.
• Complete annual National Critical Access hospital Quality Inventory and Assessment Survey.
• Educate staff on new quality measures, care protocols, compliance rules, and quality improvement strategies.
• Maintain regulatory readiness for survey reviews, audits, and inspections.

Qualifications & Skills:

Degree from an accredited school of nursing or college. Currently licensed as a registered nurse from the Nebraska State Board of Nursing. Bachelor's degree preferred. Preferred three years of nursing experience in a hospital setting. Demonstrates knowledge base of infection transmission and prevention principles.

Benefits We Offer:

• Competitive wages
• Comprehensive health, dental, and vision insurance
• Retirement savings plan
• Professional development opportunities
• Supportive and collaborative work environment
• Paid time off
• Sick pay

Why Join Us?

At Johnson County Hospital, we value our team and foster a supportive environment where you can thrive. Join us to make a difference in the lives of our patients and their families.

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