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Job Summary

The Quality Assurance and Regulatory Compliance Manager supports quality, infection control, regulatory compliance, and maintains staff educational programs at the Buffalo Surgery Center. This role ensures staff competency, regulatory compliance, and continuous improvement in patient care and safety standards.

Duties and Responsibilities

+ Demonstrate our core values of being patient centered, team focused, service driven, accountable, and innovative every day.

+ Manages the Infection Control Program, including annual risk assessments, monthly audits, and Environment of Care (EOC) rounds.

+ Monitors environmental services performance, coordinates pharmacy consultant visits, and oversees sterilization practices to ensure adherence to quality and safety standards.

+ Leads surgical site infection (SSI) investigations, reports findings to QAPI, and ensures compliance with Department of Health (DOH), Centers for Disease Control and Prevention (CDC), and other regulatory requirements.

+ Maintains employee health records, enforcing seasonal vaccination protocols.

+ Overseeing construction-related ICRA processes and the facility’s water management program.

+ Supports and implements organizational quality, safety, and compliance initiatives by co-leading quarterly QAPI meetings and reviewing key quality measures.

+ Maintains and updates policies and procedures to ensure ongoing accreditation readiness and regulatory compliance.

+ Responsibilities include coordinating root cause analyses (RCA), overseeing mandated reporting, and managing electronic compliance systems.

+ Supports safety and emergency preparedness through facility drills, incident reporting, and follow-up.

+ Serves as the administrative liaison for the Safety Committee, providing leadership updates on safety trends and performance indicators.

+ Leads orientation and onboarding for all new staff, ensuring smooth integration and compliance with organizational standards.

+ Develops, implements, and tracks education and competency programs, including annual mandatory training, OSHA and accreditation requirements, and clinical certifications such as BLS and Sedation.

+ Organizes preceptor education, vendor in-services, and ongoing staff development initiatives, while maintaining accurate education and credentialing records.

+ Supports continuous learning through educational communications and department-specific training as needed.

+ Maintain the facility EMR and perform quality audits on charting.

+ Evolve in your role when performing supplemental responsibilities as assigned.

Qualifications

Requirements and Qualifications

+ Bachelor of Science in Nursing (BSN) required.

+ Current New York State Registered Nurse (RN) license in good standing.

+ Minimum of five (5) years of nursing experience, including at least two (2) years in the operating room; orthopedic and/or GI experience preferred.

+ Basic Life Support (BLS) certification required; BLS Instructor and Sedation Certification preferred.

+ Certification in Ambulatory Infection Prevention (CAIP) desirable. Must be obtained within the appropriate timeframe upon meeting eligibility requirements for the exam.

+ Microsoft Word, Excel, Outlook, and Teams.