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Director of Quality Improvement-Nursing in Milwaukee, WI at Ascension Living

Date Posted: 3/22/2018

Job Snapshot

  • Employee Type:
  • Location:
    9255 North 76th Street
    Milwaukee, WI
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description


Initiates and oversees the development of a comprehensive safety/quality/performance improvement programs. Assess the safety/quality/performance improvement and training needs of the community.


Quality Assessment and Performance Improvement

  • Implements a comprehensive safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives.

  • Provides strategic oversight for resident safety and quality committee with accountability for distribution of organizational communication within the campus.

  • In conjunction with the Medical Director and organizational leadership, directs and coordinates safety/quality performance improvement initiatives.

  • Collaborates with the Director of Nursing to ensure that clinical services are provided in accordance with standards established through state and federal regulations and accreditation standards.

  • Monitors compliance of policy and procedure for regulatory compliance, evidence based care and standards of practice.

  • Initiates and oversees the community Safety Event Review Team (SERT). Provides strategic oversight of proactive and reactive resident safety activities including root cause analysis and failure mode effects analysis in regards to the facilitation of process, planning, implementation and evaluation of effectiveness of process changes.

  • Prepares reports and seeks consultation from the Subsidiary Board regarding resident safety, performance improvement programs and staffing effectiveness and other reports as requested.

  •  Proactively educates leadership and staff regarding regulatory issues, new statutes/guidelines and safety/quality/QI activities.

  • Leads the QAPI process and regularly communicates QI and quality/safety activities to leadership and throughout the community.

  • Works effectively in multi-disciplinary teams, leading and facilitating, to move the community to new areas of excellence.

  • Coordinates the activities of the PSO (Patient Safety Organization).

  • Analyzes and identifies trends using the events reporting system. Leads improvement activities to correct any negative trends.

  •  Other duties as assigned



  • N/A


  •  Bachelor’s degree from a recognized accredited college or university

  • Minimum 3 years of applied clinical experience as an RN in a health related field Long Term Care experience preferred and two years’ experience in Quality Improvement



  • State licensed RN

Job Requirements


  • QAPI principles; Solid clinical knowledge of post-acute and SNF care.

  • Ability to formalize and present training material to groups and individuals. Work well in a team environment that promotes inclusiveness and communication among team members. Able to lead, develop and empower associates to improve systems and processes

  • Must possess strong collaborative, interpersonal, organizational, multi-tasking, verbal and written communication skills, and a desire to create a high-performance, effective team that can produce consistent, demonstrated results.

  • Must demonstrate on an ongoing basis the ability to develop and maintain good working relationships with co-workers and ministry leadership.

  • Competencies needed for this position include strong interpersonal relationship skills, detail oriented, work in collaboration with others, demonstrate a high degree of integrity and personal commitment, possess strong analytical skills, be able to work independently and manage multiple deliverables at the same time.

  •  Ability to function in a matrix environment and demonstrate a passion to succeed be self- motivated, dependable, committed, and a willingness to see a project through to its conclusion.

  • Working knowledge and proficiency with Microsoft Office is required.


The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Occasionally required to carry or lift items weighing up to 10 pounds.

  • Occasionally required to carry or lift items weighing up to 25 pounds for short distances. Required to obtain assistance of another qualified associate when attempting to lift objects over 25 pounds.

  • Occasionally required to stand or walk.

  • Frequently required to sit in a stationary position.

  •  Occasionally performs activities that require stooping, bending and reaching, squatting, balancing, and trunk twisting throughout the day.

  • Constantly able to communicate verbally and in written form.

  • Frequently able to detect and discern both loud and soft sounds such as phone calls and customer questions.

  • Constantly able to use hands and fingers to type, write, and file.

  • Frequently able to use near vision for viewing computer monitor and written materials.

  • Occasionally required to detect unusual odors that could indicate environmental issues.


Position is Category III of Potential Exposure, which includes tasks that involve no exposure to blood, body fluids, or tissues, and Category I tasks (expected exposure to blood, body fluids, or tissues) are not a condition of employment. OSHA Blood borne Pathogen Standard 1910.1030(c)(2)(i) more specifically defines Category III Potential Exposure as: Normal work routine involves no exposure to blood, body fluids, or tissues. Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care, first aid or to be potentially exposed in some other way.

  • The noise level in the work environment is usually moderate.

  • Work is generally performed in an indoor, well-lighted, well-ventilated, heated and air-conditioned environment.


  • Possess a personal presence characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Ascension Living.

  •  Possesses a willingness to learn and apply Catholic Healthcare principles and values in the discernment and decision making process for all matters.

  • Creates and maintains a partnership between associates, the community, and those we serve that fosters an environment honoring individual preferences, choices and traditions.


  • Reports to: Community Executive Director or Administrator

  • Supervises: N/A

  • Supports:

  •  Collaborates: Internal/External Colleagues when appropriate.

The above statements are intended to describe the general nature and level of work being performed by the associate. They are not intended to be an exhaustive list of all responsibilities, duties, skills required of personnel so classified and it is not a contract express or implied. Ascension Living may change, revise, or update job descriptions upon business discretion.