Careers

Quality Assistant – Full Time

Status/Type: Non-Exempt

Department: Quality

Shift: Days

Reports: Director of Quality

Original Date: 22/07/2026

Revised Date:

Reviewed Date:

General Summary

The Quality Assistant supports the Quality Management System and promotes desired clinical and hospital system outcomes. The position encompasses support for the following programs and initiatives that are managed within the Quality Management Department: Infection Control, Employee Health Nurse, Clinical Education, Clinical Informatics, DNV Accreditation Compliance, supports the policies and programs at CPSH which are in place to maintain quality driven programs for CPSH patients, visitors and employees.

Duties and Responsibilities

  • • Attend daily discharge planning meetings in the absence of the Quality Manger to ensure the patient needs are being met to prevent Healthcare Acquired Infections (HAI).
  • • Assist to track and trend previous infections to identify patterns, and act to prevent the trend from continuing.
  • • Responsible for compiling, disseminating, and reconciling Physician’s Monthly Infection Control Letters.
  • • Assists with obtaining initial employee health status of all applicants prior to orientation day including proof of immunity for the following: MMR Immunity, Varicella Immunity, and Hepatitis B Immunity or declination as well as TB status, COVID vaccination status and Flu vaccine/ denial or declination and performing N95 fit test on employees as applicable.
  • • Entering and retrieving vaccination into LINKS as applicable.
  • • Participation in new staff orientation in the absence of the Quality Manager
  • • Assist with setting up new hire courses in HealthStream for new employees and yearly regulatory courses for all employees and entering in-house in-services on employees’ transcript.
  • • Assist with design and implementation of new and innovative educational programming by translating current evidence into a practical application strategy in the clinical and non-clinical setting.
  • • Assist with monitoring compliance with resuscitation certifications -monitoring expiration date, sending notification email and registering for class
  • • Assist Quality Manger with preparing for BLS/ACLS and PALS classes, including preparing class documents, updating files and spreadsheet after completion of class
  • • Enters Incident Reports into the EMR and reconciliation each month
  • • Assit with compiling data and preparation of presentation for Quality Meeting including typing QMC minutes
  • • Assists with any new Quality Measure implementation and tracking
  • • Run ADHOC and manipulate data as needed for Quality Reporting
  • • Assist with creating physician order sets, templates, E-forms and staying current with updates and disseminating information to departments as needed.
  • • Assist with preparing and submission of necessary patient information to Press Ganey for OSACHAPS and HCAHPS surveys.
  • • Attends all Quality-related meetings and records and prepares minutes for the committee chairperson.
  • • Performs duties to support projects of the CNO / Quality Manager including but not limited to evaluation of performance improvement project progression, identification of new performance improvement projects, internal audits, participates in survey preparation and survey process with CMS, DNV, DHH, OSHA, or other agencies as necessary.
  • • Responsible for PRO-THA/TKA phone calls, follow-ups and tracking spreadsheet
  • • Tracking and reporting Hand Hygiene, MRSA/NOZIN and Environment of Care (EOC) rounds
  • • Other duties as assigned or required.

Education/Qualifications

  • • Pre-employment requirements must be met
  • • Proficiency in EXCEL, WORD, PPT and OUTLOOK required
  • • BLS which follows the American Heart Association guidelines recommended
  • • Experience in healthcare preferred

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