Quality Improvement Nurse

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

The Quality Improvement Nurse plays a critical role in advancing high-quality, safe, and reliable patient care across the organization. Grounded in clinical expertise and evidence-based practice, the individual partners with nursing, interdisciplinary teams, and leadership to analyze clinical outcomes, identify improvement opportunities, and guide the implementation of sustainable solutions.  This role blends nursing-focused improvement with system-wide quality methodologies, providing coaching, education, and performance analysis while supporting regulatory readiness, high-reliability principles, and alignment with organizational strategic goals. The individual supports ministry and system initiatives to ensure consistency with best practices, accreditation standards, and the organization's mission to deliver exceptional care.

Bachelor’s Degree in Nursing is required. (After January 4th, 2026, the education level required will be a BSN.  Colleagues assigned to this role prior to January 4th, 2026 who do not have a BSN may continue to work as a Quality Improvement Nurse.) 

Master’s degree in Nursing, Healthcare, Quality, Public Health, or related discipline is preferred.

3 years of clinical nursing experience is required.

2-3 years of experience in quality improvement, patient safety, or clinical performance analytics is required.

Experience conducting audits, interpreting clinical data, supporting regulatory compliance, or leading improvement initiatives is preferred.

Licensed as a Registered Nurse (RN) in the state of practice is required.  Wisconsin:  RNs may practice with a valid multi-state RN license as outlined in the Nurse Licensure Compact rules.

Certification Professional Healthcare Quality (CPHQ) is required or within 2 years of hire date.

LEAN/Six Sigma training or certification is preferred.

Strong ability to analyze, interpret, and synthesize clinical data, outcomes, and workflow information. Excellent written, verbal and, interpersonal communication skills.

Demonstrated ability to coach and provide constructive feedback to clinical and non-clinical teams.

Ability to build effective relationships with nursing, medical staff, and interdisciplinary colleagues.

Strong prioritization and project management skills; ability to manage multiple deadlines.

Knowledge of performance improvement methodologies, high-reliability principles, and frontline engagement strategies.

Working knowledge of regulatory and accreditation requirements (Joint Commission, CMS Conditions of Participation).

Ability to work independently with minimal supervision while collaborating effectively across teams.

Applies clinical knowledge to evaluate patient outcomes, conduct chart reviews, audit workflows, and identify process gaps or improvement opportunities.

Performs data analysis and uses findings to guide decision-making, validate trends, and measure the effectiveness of improvement initiatives.

Provides coaching, training, and education to nursing and interdisciplinary teams on quality improvement, evidence-based practice, and documentation accuracy.

Supports peer review processes, case follow-up, and ongoing engagement with clinical teams to promote a culture of quality, safety, and high reliability.

Monitors, trends, and analyzes patient safety events (near misses, good catches, harm events) and facilitates safety huddles to support real-time mitigation.

Leads or supports RCAs, ACAs, FMEAs, and other proactive risk assessments to identify system vulnerabilities and drive corrective actions and follow-up.

Ensures accurate and timely safety event reporting while partnering with Nursing, Quality, Risk, Infection Prevention, and Medical Staff to coordinate investigations and share learnings.

Supports organizational readiness for Joint Commission, CMS, and other regulatory or accreditation surveys and assists in developing action plans to address findings.

Reinforces compliance with organizational policies, clinical standards, and safety requirements across units and teams.

Collaborates with nursing, ministry, and system leaders to align improvement initiatives with organizational strategic goals and Quality & Safety priorities.

Participates in unit, ministry, and system-level performance improvement teams, councils, and committees, escalating trends or opportunities as appropriate.

Supports implementation and sustainability of high-reliability practices, monitoring outcomes and ensuring improvements remain measurable, standardized, and effective over time.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Reduces the risk of healthcare acquired infections through compliance with current CDC hand hygiene guidelines and facility policies including the wearing of Personal Protective Equipment (PPE), if applicable.  Utilizes standard precautions during patient contact and when handling contaminated materials.  Demonstrates compliance with National Patient Safety Goals.

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline.  Commits to keeping all patient, student or colleague information confidential and maintains excellent interpersonal communication with the health care team colleagues.

Emphasizes a holistic approach to patient care-attending to body, mind, and spirit while upholding ethical principles with patient care and all other aspects of work.  Actively involves the patient and family in decisions about care.  Promotes quality care by participating in organizational councils/committees and/or support of related process.  Documents services provided to patients in the electronic medical record in accordance with policy and requirements. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other