Job Summary

Acts as center’s resource for quality systems, clinical practice guidelines, specialty programs, regulations and enforcement, and clinical safe business practices.Responsible to assess the training needs of nursing staff and to develop,implement,evaluationanddocumentstaffdevelopmentprogramsincludingGeneralOrientation,JobSpecific Orientation, In-Service, and Continuing Education Programs for nursing department personnel.Functions within the scope of the state’s Nurse Practice Act for R.N. licensure.A registered licensed nurse designated to act as the coordinator of an infection prevention and control program to oversee the general application of the infection control guidelines.

EssentialJobFunctions

Everyefforthasbeenmadetomakeyourjobdescriptionascompleteaspossible.However,itinnowaystatesorimplies that these are the only duties you will be required to perform.The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

StaffDevelopmentResponsibilities

• Overseesimplementationoftheorientationplanfornursingstaffandcontractors
• Participatesingeneralorientation
• Actsaspreceptor,coachandresourcepersontoassistnursingdepartmentemployeestosuccessfullycomplete orientation
• OverseesdocumentationoforientationofnursingstaffincludingskillvalidationusingSkillsandTechniques evaluations
• Coordinatesandassistswithannualskillstraining/validationofnursing staff
• Overseesnursingassistanteducationincludingteaching/managingCNAclasses;ensuresin-servicecontent meets regulatory requirement and individual needs
• Maintainsrecordsofin-servicetrainingsconductedincludingcontent,attendanceandfacilitatestransferof information to facility record-keeping system
• Monitorscompletionstatusofmandatoryin-servicetrainings;assistsnursingemployeesinunderstandingtheir responsibilities and accessing required training
• Collaborateswithleadershipandassistsinplanning,coordinatingandconductingtrainingrelatedtofederal,state, local and company requirements
• Coordinatesdemonstrationsandcompetencyvalidationrelatedtonewequipmentorprocedures
• Servesasfacilityliaisontoapprovedstudentaffiliations–providesorientationofstudentstofacilityandclinical processes; communicates with instructor regarding student observations; validates students’ compliance with facility prerequisites
• ObtainsandmaintainscurrentCPRcertification;coordinatesschedulingandconductson-siteCPRtraining
• Attendsandparticipatesinscheduledin-servicetraining,educationalclassesandmeetingstomaintaincurrent certification as applicable and as managed by regulatory agencies and company policies
• ParticipatesinQAPIprogramusingcompanyapprovedtools
• AttendsandparticipatesinCircleofCare classes

QualityAssuranceandPerformanceImprovementResponsibilities

• Functionsasthefacilityabaqis®coordinator–makesassignmentsforcompletionofassessments/interviews; tracks/validates sample completion; reports status during Eagle Room meeting weekly; replaces discharged patients in sample
• Providesongoingeducationrelatedtoabaqis®andqualityimprovementinitiativestofacilitystaff
• Coordinatesabaqis®Investigationprocesswithfacilityadministrationandclinicalservicesteamandcoordinates and monitors follow-up response plan
• Initiatesandmonitorsperformanceimprovementplansinabaqis®
• Participatesinclinicalriskidentification,planning,processimprovementinitiatives
• Participatesinoccurrenceinvestigationsasrequested
• AssignsQAPItools/roundscompletionaccordingtoannualcalendar
• Attendsandprovidesabaqis®trendreportstofacilityQAPICommittee

InfectionPreventionResponsibilities

• Reportsinfectioncontroltrendsthroughtheuseofanelectronicsurveillancesystem
• Reviewsinfectionreports,analyzesdataandmakesrecommendationstotheInfectionControlCommitteeor QAPI Committee and Antibiotic Stewardship Committee
• Assistsinidentificationofinfectioncontrolissuesandconductsbothprocessandoutcomemonitoring
• Coordinatesandmonitorsmonthlydepartmentalinfectioncontrolroundsprocesses
• Collects,analyzesandprovidesinfectioninformationonin-houseinfectionstonursingstaffandotherhealthcare practitioners
• Coordinatesoutbreakinvestigationswiththedirectorofnursingandmedical director
• AssistswithrequiredCOVIDinfectiontracking/reportingandvaccine tracking/reporting
• Coordinatesannualinfluenzapreventioncampaignforpatientsandemployees
• Providesmonthly,quarterlyandannualreportsfortheQualityAssuranceandPerformanceImprovement Committee
• PreparesrecommendationsforchangesincenterpracticetotheQualityAssuranceandPerformance Improvement Committee
• Co-chairstheAntibioticStewardshipCommittee
• Partnerswiththefacilitymedicaldirector,directorofnursingandconsultantpharmacisttoimplementand maintain an antimicrobial stewardship program to ensure appropriate antibiotic utilization
• Collaborateswithhumanresourcesmanageronexposurecontrolplanincludingannualsafetysharpsevaluation, tracking hepatitis vaccination and post-exposure evaluation and follow-up
• Collaborateswithhumanresourcemanagerintrackingemployeeillnessineverydepartment
• Makes recommendations for work restrictions based on CDC Recommendations for Work Restrictions and collaborateswithMedicalDirectorandhumanresourcestoinstructemployeesonwhentheycanreturntowork after experiencing a communicable disease
• Collaborateswithhumanresourcesonreviewandimplementationoffacilityrespiratoryprotectionprogram including annual review
• CoordinateseffortstoensureemployeesdesignatedtouseN95respiratorshavebeenmedicallyevaluatedandfit tested
• Coordinatescompletionofongoingimmunizationtrackingactivitiesandimplementingmeasurestoimprove compliance, including influenza, pneumococcal and tuberculosis
• ConductsfacilityAnnualTBRiskAssessmentbasedonCDCTBRiskAssessmentandreportsfindingsto Infection Control Committee and, or QAPI Committee
• Assistsineducatingnewlyhiredcenterstaffoninfectionpreventionandcontroltechniquesincludinghand hygiene, blood borne pathogens, exposure control, PPE utilization and sharps handling
• Ensureshealthcarepersonnelreceiveinfectionpreventionandcontroltrainingandothermandatoryeducation related to infection prevention and control on an annual basis and as indicated

InfectionPreventionResponsibilities,continued…

• Coordinatesandassistswithobservationcompetenciesofclinicalstaffincludinghandhygiene,pericare,wound care, general infection control principles, PPE use and don/doff competencies, equipment cleaning, glucometer disinfection, transmission precautions, sharps management
• Assistsinthereviewofinfectionpreventionandcontrolpolicies,programand procedures
• Assistscentertoidentifygapsininfectionpreventionandcontrolthroughcompletionofannualinfectioncontrol risk assessment, identifies areas of priority and assists in d