Job Abstract

Job Summary

Reporting to the VP of Quality Assurance and patient Experience, the Manager of Infection Prevention and Control is responsible for providing leadership and support across the organization in all aspects of the infection prevention process. In the area of infection prevention and control this position is responsible for supporting executive, administrative and medical staff leadership, as well as clinical and operational staff with initiatives to improve quality, prevent healthcare associated infections and ensure mandatory compliance with infection control, prevention, reporting and education. This includes IPAC activities in both inpatient and ambulatory and offsite areas. The goal of the department is to lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes. This position oversees and promotes accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation. This also includes supporting Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep staff and providers aware of all regulatory and accreditation standards. This position oversees the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system’s public transparency, HSCRC Pay for Performance programs, and penalty programs. This position is responsible for managing/overseeing specific system projects related to infection prevention and control. In addition, he or she is responsible for overseeing and managing Frederick Health’s participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System.

The Manager provides administrative direction for the department’s operations, budgeting, development of information systems and coordination of information flow. The Manager supports, and is responsible for incorporating into job performance, the Frederick Health mission, vision, core values and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements, and the Frederick Health Standards of Behavior.

Example of Essential Functions

· Participates in and provides leadership to the establishment, implementation, and maintenance of the organization’s clinical quality improvement strategies, programs, and methods related to regulatory compliance and infection prevention

· Develops, implements, and monitors the effectiveness of strategies and plans

· Designs and coordinates communication of regulatory and hospital acquired infection improvement activities and outcomes and results to enhance programming

· Communicates concepts and issues effectively (written and oral) across all service lines within the organization

· Provides quality reports and metrics to stakeholders in an ongoing and ad hoc basis

· Identifies appropriate national and state databases for comparison of regulatory and infectious disease data

· Able to convert data into actionable information

· Coach, train, and develop teams to create processes to consistently achieve best practices that is evidence based

· Facilitates problem-solving within and between program areas

· Lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes

· Manages and promote accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation

· Supports Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep system aware of all regulatory and accreditation standards

· Manages the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system’s public transparency, HSCRC Pay for Performance programs, and penalty programs.

· Manages specific system projects related to infection prevention and control.

· Manages and validates Frederick Health’s data and participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System

· Assures the data system for electronically reporting infections and hospital acquired infections or any epidemics function and are accurate

· Interpret and apply external regulations and standards in relation to health care delivery the hospital and ambulatory and outpatient setting

· Manages projects related to Ebola and other infectious disease epidemic preparedness and those teams associated with those diseases

· Manages projects related to the Environment of Care as it relates to regulatory compliance especially those related to patient safety, staff safety and the prevention of infectious disease for the organization

· Collaborates with the key leaders of the Environment of Care to assure compliance with TJC, state, CMS, local government and OSHA

· Maintains contact with legal counsel and risk management regarding medical-legal matters

· Maintains current knowledge of TJC, CMS, ACC national quality indicator guidelines, Magnet and NDNQI and assesses compliance for assigned areas

· Executes effective improvement projects through multidisciplinary team collaboration

· Assures issues are communicated to appropriate committees or individuals and that issues have timely resolution.

· Interacts/interfaces with all members of the medical staff, nursing and ancillary departments to discuss pertinent regulatory issues and follow up of patients

· Attends and supports committees as appropriate including the Environment of Care Committee, Quality Coordinating Council, the Patient Safety Committee, and various quality related Nursing Committees

· Work collaboratively with the Board, Administration and Leadership

· Creates and maintains a positive work environment by being responsible for all aspects of personnel management from recruitment, staff development, create job performance standards, conduct performance evaluations, evaluate workload, promote optimal productivity, team building, identify/provide excellent customer service, resolve staffing issues, counsel personnel and following the process for disciplinary action when warranted

· Plans and allocates resources to effectively staff departments and accomplish productivity and quality goals

· Plans, evaluates, and improves the efficiency of processes and procedures to enhance speed, quality, efficiency, and results

· Formulates business decisions that are financially responsible, accountable, justifiable, and defensible in accordance with organization policies and procedures

· Establishes and maintains relevant controls and feedback systems to monitor the operation of the departments

· Reviews performance data that includes quality, satisfaction, engagement, and financial reports

· Monitors and measures productivity, goal achievement, and overall effectiveness

· Participates in the preparation and maintenance of reports necessary to carry out the functions of the areas of responsibility

· Prepares periodic reports for management to track goal accomplishment

· Manages human resources activities in regards to: recruiting and selection; hiring and termination, training, development, mentoring, counseling, and performance evaluations

· Performs other duties as assigned

Required Knowledge, Skills and Abilities

• Knowledge of company policies, and state/federal regulatory and accreditation standards.
• Ability to work with or lead interdisciplinary teams.
• Knowledge of federal, state, joint commission and other regulatory standards
• Ability to build and maintain professional knowledge
• Excellent communications skills both verbally and written.
• Ability to create collaborative working relationships
• Ability to create and maintain a participatory environment.

Minimum Education, Training, and Experience Required

Bachelor’s Degree in Nursing or other related field required

Ten years work experience in a healthcare setting required.

CIC certification required.

Team facilitation and experience with hospital accreditation standards and survey process.

Patient Contact

Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:

Performance of job does not require patient contact

Physical Demands:

Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

• Bloodborne Pathogens Exposure Risk: Category C – NO exposure to blood or body fluids

• Works in well-lighted/ventilated office areas.

• Extended work hours beyond 8 hours per day and 40 hours per week.

Reporting Relationship:

Reports to the VP of Quality Assurance and patient Experience