ASC Clinical Director

Job Summary

The Clinical Director is an integral member of the management team and is responsible for providing guidance and support related to Performance Improvement, Certification, Accreditation, Patient Safety, Infection Prevention, and Employee Health activities across assigned freestanding Ambulatory Surgery Centers (ASCs).

This position supports continuous improvement in CMS ASC Quality Measures, specialty quality measures, and patient experience outcomes, while serving as a resource to assigned ASCs for quality benchmarking, reporting, data analysis, and identification of trends and opportunities for improvement.

The Clinical Director also provides leadership and guidance for Infection Prevention and Employee Health, helping standardize processes and promote regulatory compliance across assigned facilities. In collaboration with the Risk Management and Patient Safety teams, this role supports initiatives designed to strengthen patient safety, reduce organizational risk, and promote high-quality care across the assigned ASCs.

Key Responsibilities

Performance Improvement, Accreditation & Certification

• Ensure processes are in place for the collection, measurement, reporting, and performance improvement of quality measures required by CMS, state regulatory agencies, accreditation organizations, and other applicable governing bodies.
• Assist with the development of specialty-specific benchmarking metrics and ensure appropriate processes are established for measuring, reporting, and improving performance.
• Support and participate in corporate task forces and performance improvement teams focused on quality initiatives.
• Assist the VP of Clinical Operations (ASC) with preparation of materials for quarterly corporate Quality Council meetings.
• Stay current on new and changing state, CMS, accreditation, and specialty-specific requirements and communicate relevant updates to assigned ASCs.
• Support ASCs with required regulatory reporting, including reporting through QualityNet.
• Assist with the implementation of clinical and evidence-based content designed to improve the overall quality of care and related processes, including clinical documentation, physician order management, and plans of care, when applicable.
• Perform quality reviews to help ensure the integrity and accuracy of clinical and evidence-based content prior to release.
• Recommend processes to ensure evidence-based clinical content remains current and accurate.
• Assist with drafting policies governing the development, use, and maintenance of clinical content.
• Provide support and education related to Patient Experience surveys and strategies for improving scores.
• Review Patient Experience results at least quarterly for assigned ASCs to identify trends and opportunities for improvement.
• Assist the VP of Clinical Operations (ASC) with accreditation and certification activities, including participation in mock surveys and development of plans of correction.
• Conduct mock surveys for assigned ASCs, develop action plans to address identified areas of improvement, and follow up to promote sustained compliance.

Infection Prevention & Employee Health

• Serve as a subject matter resource for Infection Prevention and Employee Health activities across assigned ASCs.
• Ensure the Infection Prevention designee at each ASC has demonstrated and documented required competencies.
• Provide orientation and support for staff members who are new to Infection Prevention and Employee Health responsibilities.
• Ensure corporate template policies related to Infection Prevention and Employee Health are appropriately disseminated and aligned with applicable state regulatory requirements.
• Provide or coordinate on-site Infection Prevention and Employee Health support as needed.
• Assist with the development of tools, reports, and resources to support performance improvement initiatives related to Infection Prevention and Employee Health.
• Participate in recurring Infection Prevention and Employee Health networking calls and workgroups.
• Lead networking calls related to Infection Prevention and Employee Health topics specific to assigned state markets.
• Assist facilities with regulatory reporting, including NHSN reporting and internal Surgical Site Infection (SSI) investigations.

Risk Management & Patient Safety

• In collaboration with the Risk Management and Patient Safety teams, support assigned ASCs in efforts to minimize risk, improve patient safety, and reduce potential liabilities.
• Conduct risk management assessments and develop facility-specific work plans based on assessment findings.
• Provide ongoing follow-up and support related to identified risk management opportunities.
• Assist facilities with required state reporting within established regulatory timeframes.
• Review events entered into the event reporting system and provide guidance to facility risk management and leadership teams when additional information, follow-up, or revisions are needed.
• Notify the ASC Clinical Operations team of Sentinel Events and assist with related investigations.
• Assist assigned ASCs with the development of credible Root Cause Analyses (RCAs) following significant incidents or adverse events.
• Assist with preparation of the Quarterly Risk Management Report for facility Governing Board review.
• Prepare reports for facility leadership and Risk Management that include:
• Written findings
• Identified or cited deficiencies
• Recommendations for achieving compliance
• Recommended best practices

Qualifications

Knowledge Required

• Strong knowledge of the healthcare industry and applicable local, state, and federal healthcare regulations.
• Knowledge of quality and performance improvement activities within the ambulatory surgical setting.
• Working knowledge of accreditation and certification standards and requirements.
• Understanding of Infection Prevention, Employee Health, Risk Management, and Patient Safety principles.

Education

• Required: Bachelor's degree in Nursing, Healthcare, or a related healthcare field.
• Preferred: Master's degree in Healthcare, Quality, Business Administration, or a related field.

Professional Experience

• 3-5 years of leadership experience in areas such as:
• Performance Improvement
• Accreditation and Certification
• Risk Management and Patient Safety
• Infection Prevention
• Employee Health

Skills & Abilities

• Strong computer proficiency, including experience with databases and software applications necessary to perform the essential functions of the position.
• Demonstrated knowledge of process improvement methodologies, process analysis tools, and quality improvement principles.
• Strong facilitation, problem-solving, and organizational skills.
• Excellent verbal and written communication skills.
• Ability to analyze trends, identify opportunities for improvement, and effectively communicate recommendations to facility and organizational leadership.
• Ability to collaborate effectively with clinical leaders, facility teams, and corporate partners across multiple locations.