• Maintain current Infection Control and Prevention plans, policies, procedures and programs.
• Gather, disseminate and document information on patient care quality and infection prevention to facilitate compliance with requirements of accrediting and regulatory agencies.
• Perform and document annual Infection Control Risk Assessment.
• Coordinate and integrate all Infection Control and Prevention activities within the Hospital.
• Advise and assist medical staff and allied health care personnel in the quality / infection prevention process.
• Provide an ongoing assessment of the Infection Control and Prevention elements of the quality improvement program.
• Coordinate the bi-monthly Infection Control Committee: Prepare the meeting agenda, minutes, and related meeting materials. Maintain a close liaison with the Infection Control Committee Chairperson / Program Director for Infectious Disease.
• Keep appropriate committees informed of changes in accrediting and regulatory standards related to Infection Control and Prevention; maintain a close liaison with other hospital department heads to assure coordination, standardization and continuity of Infection Control programs.
• Provide in-services on Infection Control and Prevention topics, plans, policies, procedures and programs as needed.
• Coordinate and/or perform studies related to Infection Control / Quality Improvement and prepare resulting reports.
• Utilize the “Plan-Do-Check-Act” methodology of performance improvement.
• Establish and maintain tracking systems for reporting infection control and surveillance data and ensuring that the programs result in quality improvement.
• Keep current with state laws, federal laws and regulatory agency requirements for hospitals regarding infection control, quality management, and regulatory data reporting.
• Ensure that policies, procedures, protocols, and processes reflect the most up-to-date evidence and guidelines from professional organizations such as:
o Association for Professionals in Infection Control and Epidemiology (APIC);
o Center for Disease Control and Prevention (CDC);
o Healthcare Infection Control Practices Advisory Committee (HICPAC);
o Society for Healthcare Epidemiology of America (SHEA);
o Infectious Diseases Society of America (IDSA);
o World Health Organization (WHO);
o and others.
• Assist Administrator/CEO in developing Medical Staff Bylaws, rules, and regulations to assure compliance with regulatory standards related to Infection Control and Prevention.
• Act as the hospital Safety Officer, and maintain oversight of the Physical Environment and Safety Program (aka the Environment of Care) and all related Plans.
• Act as a liaison between Acuity and the host hospital for issues related to the Environment of Care and Safety.
• Assist DQM and Clinical Quality Manager in regulatory survey preparation and ongoing compliance.
• Ensure compliance with measures for preventing exposure to blood borne pathogens.
• Establish and maintain tracking systems for reporting data and detecting infectious outbreaks in all age groups of patients (18 years and over).
• Ensure that all employee occupational health requirements are met and maintained; including but not limited to annual PPD, fit testing, and mandatory vaccinations.
• Coordinate annual vaccination programs for employees and patients.
• Coordinate hospital-wide hand hygiene program.
• Identify, investigate, and report communicable diseases as required by law.
• Educate staff and patient population about infection risk, prevention, and control.
• Participate in orientation of newly hired staff to provide a foundation of education related to infection control and prevention.
• Support current and future Quality Improvement plans, policies, procedures and programs.
• Gather, disseminate and document information on patient care quality to facilitate compliance with requirements of accrediting and regulatory agencies.
• Abstract paper and electronic medical records to obtain necessary data elements for submitting quality data to regulatory bodies.
• Serve as the subject matter expert regarding documentation standards necessary to support compliance with reportable quality and safety metrics.
• Under the direction of the RCQO, conduct audits and prepare requested reports relative to quality and safety metrics. Monitor and maintain related records.
• Keep appropriate committees informed of changes in accrediting and regulatory standards relative to quality data reporting initiatives.
• Maintain tracking systems for reporting data and ensuring that the programs result in quality improvement.
• Comply with established Safety and Patient Safety Program practices.
• Recognize patient abuse and follow policy for making appropriate referrals/interventions.
• Takes administrative call as assigned.
CLINICAL QUALITY COORDINATOR
• Assists CQO and Clinical Quality Manager by gathering, disseminating, and documenting information on clinical quality and patient safety to facilitate compliance with requirements of accrediting and regulatory agencies.
• Assists with data collection and preparation related to Root Cause Analyses, Healthcare Failure Mode Effects Analyses, Internal Audits, Ongoing Provider Performance Evaluation, Grievances, and Risk Assessments.
• Assists with annual review of the Quality Management System (Performance Improvement Plan).
• Coordinates concurrent and retrospective medical record review studies and prepares resulting reports.
• Assists with maintaining a survey-ready hospital environment.
• Keeps current with state and federal laws and regulatory agency requirements for hospitals.
• Participates in clinical rounds with the Chief Clinical Officer or designee.
• Participates in the weekly Interdisciplinary Team Meeting, the daily Flash meeting, and also family meetings as requested.
• Coordinates, performs, and follows up on internal audits.
• Assists CQO with preparation for Performance Improvement Committee, Patient Safety Committee, Medical Executive Committee, Operations Review, and Grievance Committee.
• Participates in the development and revision of policies & procedures and forms.
• Participates in the development, implementation, and monitoring of corrective action plans.
• Practices safe handling of hazardous materials. Hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.
• Participates in Performance Improvement activities.
• Complies with established facility safety practices.
• Adheres to all components to the Hospital compliance plan in performing job duties and reports any suspected violations of the Plan.
• Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
• Performs other duties as assigned or delegated by the CQO.
• Adheres to hospital attendance policy as set out in the Employee Handbook.
• Limits access to protected health information (PHI) to the information reasonably necessary to do the job and share such information only on a need to know basis for work purposes.
o (Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization. Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.
MANDATORY QUALIFICATIONS (SKILLS, EXPERIENCE, EDUCATION)
• Professional qualifications:
o Certified Infection Control Practitioner [CIC] ((or))
o Registered Nurse with current state license and minimum of three (3) years’ experience as staff nurse or team leader- Infection control certification will be required within three (3) years of hire ((or))
o Registered Nurse with current state license and minimum of one (1) year experience in Infection Prevention or CMS Quality Reporting (Inpatient Core Measures, LTCH CARE Database, or LTC Minimum Data Set) or other relevant administrative experience- Infection control certification will be required within three (3) years of hire
• Excellent communication skills
• Excellent organizational skills
• Proficiency with basic office computer programs
• Ability to work in high stress environment
• Ability to speak, read, and write English
Previous experience in Infection Control, Quality Management, Risk Management, or Patient Safety
Bachelors of Science in Nursing
Proficiency with Microsoft Excel, PowerPoint, and Word