Job Abstract

Job Summary

The Director of Quality, Patient Safety, and Infection Prevention will be responsible for the strategic oversight, planning, development, and implementation of effective Quality Improvement, Patient Safety, and Infection Prevention programs that monitor, address, and prevent quality of care, patient safety, and infection prevention  concerns.

This position will oversee the daily operations of the Quality Improvement, Patient Safety, and Infection Prevention programs. This includes leading quality improvement programs, incident review processes, root cause analyses, and evaluating effectiveness of process changes. This leader will inform, advise and make recommendations to hospital leadership about quality improvement, patient safety, and infection prevention practices. Required reporting to external agencies and oversight of program-related databases and IT systems are essential responsibilities of this position.

This position directs the identification and implementation of infection control goals and objectives including, but not limited to, appropriate selection and usage of products and equipment related to cleaning, antisepsis, disinfection, and sterilization, facility design and construction. Directs the development and implementation of educational programs designed to reduce or prevent infection. This position is responsible for directing the prevention, reporting, surveillance and controlling healthcare associated infections (HAIs) and communicable diseases for Henry Mayo Newhall Hospital.

He/She will collaborate closely with Medical Staff leadership in creating a comprehensive approach to program and system design. Additionally, this position will collaborate with the Manager of Compliance, Risk, and Regulatory to ensure regulatory and accreditation compliance and survey readiness. This position collaborates with and makes recommendations to the Henry Mayo Newhall Hospital leadership team to ensure compliance with regulatory agencies and assures facility-wide and departmental policies and procedures that comply with current regulatory standards. The Director will be responsible for the management of program personnel and fiscal and material resources.  He/She will support staff development and continuous program process improvement.

Licensure and Certification:

•  Current California RN License required
• Certified Professional in HealthCare Quality (CPHQ) required
• Certified Professional in Patient Safety (CPPS) preferred
• Certified Infection Control (CIC) preferred

Education:

• Bachelor’s degree required
• Master’s degree (MSN, MBA, MHA, or MPH) or higher preferred

Experience:

• Minimum five (5) years’ cumulative experience in any combination of the following areas:

o   Quality (required experience)

o   Performance Improvement

o   Patient Safety

o   Risk Management

o   Accreditation/Regulatory/Licensing

o   Infection Prevention and Control

• Minimum (3) years’ acute clinical care experience
• Minimum (3) years’ management experience

Knowledge and Skills:

• Demonstrates and applies leadership and management theories, principles, practices, techniques and methods to create and maintain a high-functioning, engaged team; 
• Effective oral, written and presentation skills;
• Ability to interact and collaborate with all level of the organization, including the Medical Staff
• Advocate and facilitator for continuous improvement
• Superior critical thinking skills
• Ability to prioritize and effectively execute to achieve goals
• Report Analysis: Able to develop, compile and analyze statistical reports
• Able to monitor overall performance of assigned tasks
• Provide best in class customer service
• Knowledgeable and have previous experience in performance improvement
• Knowledgeable in statistical process control, data analytics, and graph/chart display techniques

Physical Demands – Clerical/Administrative Non-Patient Care:

• Frequent sitting and standing/walking with frequent position change.
• Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
• Occasional/intermittent reaching at or above shoulder level.
• Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.
• Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.
• Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.