Summary of Duties

Collaborates in the development of quality assurance measures and audits and infection prevention policies with hospital leadership team and Director of Quality Improvement. Monitors, performs, and manages quality assurance processes including those supporting compliance to regulatory and/or accreditation standards in the hospital. Surveillance, outcome measurement and risk education activities including infection prevention and control.

Essential Job Functions:

1. Initiates and oversees the development of a comprehensive safety/quality/and PI program inclusive of the analysis and trending of data
2. Leads hospital PI/quality and infection control committees with accountability for distribution of organizational communication
3. Regulatory reporting as indicated by CMS, TJC through NHSN, LTRAX
4. Participates on MEC and P and T committee and other committees as indicated.
5. Organizes and directs Performance Improvement Committee activities and processes in coordination with physician chairman.
6. Provide annual reports to the facility and division DQIC regarding Quality/IC program as indicated
7. Assesses facility compliance with accreditation standards and regulations related to care in collaboration with facility leadership and staff
8. In conjunction with the medical staff, facility and division leadership, directs and coordinates quality/performance improvement initiatives
9. Ensures competent staff orientation and development programs
10. Fosters and maintains collaborative relationships within hospital division and with external agencies, purchasers, and stakeholders related to quality/performance initiatives
11. Regularly communicates PI and quality activities to leadership and staff
12. Implements, reviews and evaluate effectiveness of the infection prevention manuals for the hospital
13. Implements, reviews and evaluate effectiveness of the TB and BBP Plan for the hospital
14. Implements, reviews and evaluate effectiveness of the exposure control plan for the hospital
15. Implement general infection prevention and control information for employee orientation and other educational opportunities
16. Surveillance involving data collection, analysis and feedback and assist with action plan as indicated
17. Assures timely monthly surveillance and report to DCS
18. Disseminates information regarding CDC, OSHA and TJC policies and standards to hospital staff
19. Monitors environmental concerns related to infection prevention and provides consultation of preventative or corrective measures
20. Participates in weekly multi-disciplinary team meetings
21. Prepares reports as directed by Administrator and DQI hospital division
22. Collects and analyzes data pertaining to employee blood borne pathogen exposure and effectiveness, safety, and proper use of any sharps (i.e. IV catheters, IV tubing, lancets, syringes, needles, butterfly phlebotomy equipment, etc.)
23. Coordinates facility employee health.

Education

• Must be a graduate of an accredited School of Nursing, BSN preferred.
• Certification as Infection Control Practitioner preferred or obtained within one (1) year of employment.

Experience

• Minimum two (2) years experience in hospital quality and/or infection prevention and control preferred.