Quality and Infection Prevention Coordinator

Definition: The Quality and Infection Prevention Coordinator leads and coordinates organization-wide quality improvement and infection prevention programs. This position ensures compliance with healthcare standards and best practices to improve outcomes, ensure patient safety, and prevent the spread of infection.

 

Distinguishing Characteristics: This is a professional level position within the nursing administration department. The incumbent will report to the Chief Nursing Officer and will have no direct reports.

 

1.      Coordinate the hospital-wide Quality Assurance Performance Improvement (QAPI) Program, including development, monitoring, and communication of quality initiatives and outcomes.

2.      Lead the development, implementation, and evaluation of the Infection Control Plan; ensure alignment with CDC, CMS, and other regulatory guidelines.

3.      Responsible for maintaining compliance with regulatory reporting criteria, including but not limited to NHSN, HARP, and PMP.

4.      Monitor infection trends, conduct investigations, and lead outbreak response and mitigation efforts.

5.      Educate and train clinical and non-clinical staff on quality and infection prevention topics, including hand hygiene, PPE use, and patient safety practices.

6.      Participate in quality and safety committees; lead quality-related work groups and reporting processes, conducting Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA); track and trend incident reporting system for improvement opportunities and recommend implementation of QAPI methodologies as necessary.

7.      Ensure accurate and timely reporting of quality and infection prevention data to internal stakeholders and external regulatory agencies.

8.      Collaborate with Administration, Human Resources, Nursing Administration, Ancillary and Support Services departments to develop, implement, enforce, and revise the relevant policies and procedures necessary to carry out the assigned areas of responsibility including Quality Assurance/ Performance Improvement Program and Infection Prevention/Control Program.

9.      Serves as the Chair of Utilization Review Committee ensuring UR meetings and processes are efficient and produce measurable results to the benefit of the organization and the patient population.

10.  Collaborate with medical staff, nursing, and ancillary departments to ensure quality and UR goals are met and infection risks are reduced.

11.  Serve as a backup resource to the Risk Director in their absence, including assisting with incident review and response processes. Collaborate with Risk Director on reporting requirements and data abstraction.

12.  Participate in the NRHP Infection Control work groups and ad hoc workgroups as necessary.

13.  Contribute to PGH’s culture of continuous improvement and safety.

14.  Perform other related duties as assigned to support the mission and operations of Pershing General Hospital and Nursing Home.

Qualifications for employment include the knowledge, skills, and abilities required to perform a job, which are generally demonstrated through qualifying experience, education, or training.  

• Education/Experience: Bachelor’s degree in nursing, healthcare administration, or a related field. Three or more years of experience in hospital quality, infection prevention, or nursing leadership.

• Licensure/Certification: Active and unencumbered Nevada RN license required. Certification in Infection Control (CIC) preferred or must be obtained within 12 months of hire; any certifications or training which may be required by the Nevada DPBH. Basic Cardiac Life Support and Advanced Cardiac Life Support Certification required.

• Technical Skills: Knowledge of infection prevention practices, quality improvement methodologies, regulatory requirements, data analysis, and proficiency with electronic reporting tools.

• Behavioral Competencies:

  - Support PGH’s mission and values.

  - Maintain confidentiality and professional standards.

  - Demonstrate team collaboration and leadership.

 

The physical and mental requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.

 

Strength, dexterity, cognitive ability, and coordination to operate a keyboard and video display terminal using word processing and databases. Strength and stamina to bend, stoop, sit, stand, and walk for extended periods of time. Dexterity, coordination, bending and reaching to access and handle file(s); periodic lifting of files, stacks of paper or reports, references, and other materials. Moderate lifting (up to 50 pounds) may be periodically required to include some bending, reaching, squatting, and stooping. The ability to interact professionally, communicate effectively, and exchange information accurately with all internal and external customers. Mental stamina to deal with emotionally difficult situations. Ability to appropriately handle stress and interact with others, including supervisors, coworkers, clients, and customers. Regular and consistent punctuality and attendance.

 

In compliance with applicable disability laws, reasonable accommodations may be provided for qualified individuals with a disability who require and request such accommodations. Incumbents and individuals are encouraged to discuss potential accommodations with the employer.

 

Work is performed under the following conditions:

 

Regularly exposed to patient care areas and situations with potential exposure to infectious material and body fluids. Will use PPE as needed and follow infection prevention protocols. Work is typically performed in a clean, office-like environment with standard hours Monday-Friday, but may require flexibility for clinical coverage, urgent quality or infection-related issues. Frequent interruptions to planned work activities occur.