Job Summary Maintains ongoing status of quality assessment and performance improvement activities. Reviews and analyzes all systems. Integrates quality assessment and performance improvement activities with the risk management program to minimize the facility’s risk of financial loss due to claims or litigation. Serves as the Management Representative for the Quality Management System, and Clinical Safety Officer.

Benefits - Health insurance - Paid time off - Vision insurance - 401(k) - 401(k) matching - Dental insurance Job Summary Maintains ongoing status of quality assessment and performance improvement activities. Reviews and analyzes all systems. Integrates quality assessment and performance improvement activities with the risk management program to minimize the facility’s risk of financial loss due to claims or litigation.

Serves as the Management Representative for the Quality Management System, and Clinical Safety Officer.

Reports To: Chief Nursing Officer Classification: Exempt Supervises: Quality Risk Coordinator, Nurse Educator Qualifications Bachelor’s degree in Nursing (BSN) required.

Current Registered

Nurse (RN) license in the state of Louisiana or compact state.

Experience in risk management, quality assessment, and performance improvement required: Certified Professional in Healthcare Quality (CPHQ) certification preferred. Minimum of five years of experience required. OCCUPATIONAL EXPOSURE Category I exposure to bloodborne pathogens, frequent exposure to chemical hazards and may encounter radiation hazards.

RESPONSIBILITIES - Quality Assessment & Performance Improvement Program - Serves as the Management Representative for the Quality Management System. Is responsible for the process for internal reviews (internal audits) and management reviews to ensure the corrective and preventive actions are carried out and are measured for effectiveness.

- Provide oversight for the facility education program with design, implementation and evaluation for effective outcomes.



2.1 Provide leadership and oversight for orientation, onboarding, annual competencies, mandatory education, continuing education, and quality improvement education for all clinical and non-clinical personnel. 2.2 Provide administrative oversight for the facility's education program, including educational activities for employees, medical staff, advanced practice providers, residents, nursing students, scrub technician students, LSUA nursing and allied health students, contracted personnel, vendors, and other healthcare learners. Ensure educational programs are effectively designed, implemented, evaluated, and maintained to support organizational goals and regulatory compliance. 2.3 Collaborate with department leaders, physicians, educational institutions, and the Education Coordinator to ensure educational programs comply with DNV, CMS, OSHA, CDC, and organizational standards while supporting competency validation, patient safety, infection prevention, emergency preparedness, and quality improvement initiatives. 2.4 Provide executive oversight of student clinical experiences, affiliation agreements, competency requirements, and educational partnerships to ensure compliance with regulatory, accreditation, and organizational requirements. 2.5 Evaluate the effectiveness of the facility education program through competency validation, regulatory outcomes, quality metrics, survey readiness, and performance improvement data, implementing corrective actions and strategic improvements as indicated.




- Accepts accountability for the progress and development of the Organization's adopted Quality Assessment and Performance Improvement Program (QAPI). 3.1 Performs according to established quality assessment and performance improvement policies and procedures. 3.2 Supports risk management and participates in programs directed to patient and employee safety. 3.3 Objectively evaluates suggestions or grievances to identify means to improve standards of performance. 3.4 Establishes systems to identify resources required for support of the Quality Assessment and Performance Improvement Program, to monitor resource disbursement and to evaluate resource use and requirements. 3.5 Submits resource requests to the Medical Executive Committee by preparing and submitting reports that identify and project resources required for support of the Quality Assessment and Performance Improvement Program. 3.6 Successfully contributes to the quality improvement process and identifies role and contributions upon supervisor's request.
- Accepts accountability for the progress and development of the Organization’s Risk Management Program. 4.1 Maintains and implements a variance reporting system for the Facility 4.2 Receives and reviews all Variance Reports generated by personnel at the Facility before they are presented to the Administrator and/or CNO. 4.3 Works with the Administrator/CNO in investigating and analyzing all variances and all actual and vigente and potential risks at the Facility. 4.4 Takes steps to ascertain that risks are minimized through follow-up and action plans when developed. 4.5 Manages compliance with all regulatory, external and internal surveys and subsequent recommendations or action plans. 4.6 Integrates risk management data with the Facility’s Quality Assessment and Performance Improvement and Medical Executive Committee activities. 4.7 Evaluates variance patterns and trends. 4.8 Prepares reports and summarizes on all risk management findings to the QAPI Committee on an ongoing basis. 4.9 Reviews and assesses

📌 Quality Risk Nurse Director (Vega del Codorno)
🏢 CHRISTUS Central Louisiana Surgical Hospital
📍 Vega del Codorno