Infection Preventionist / Quality Coordinator

FLSA Employment Status: Nonexempt/Hourly

JOB SUMMARY

Responsible for coordination of the hospital-wide Infection Control/Prevention, and Employee Health Programs, which includes: surveillance, analysis, and reporting of healthcare associated infections; educating/training employees about infection control and prevention; and the development of organization-wide plans, policies and procedures to ensure rigorous infection control standards to meet DNV, OSHA, Public Health Department, and Center for Disease Control, CMS, and other regulatory/accreditation requirements.

Under the direction of the Chief Quality Officer (CQO), the Infection Preventionist/ Quality Coordinator is directly responsible for initiating infection control/prevention measures as directed by the Infection Control/Prevention Committee; responsible for assisting with infection control educational programs for the employees; accountable for the infection control/prevention program on a 24-hour basis; responsible for Employee Health, and concurrent reviews of specific medical records.

Also, in the Quality Coordinator portion of this role, this leader will work closely with the CQO to support and maintain the Quality/Patient Safety Program of the organization in a manner consistent with accreditation standards and regulatory requirements.

Reporting Structure: Reports to the Chief Quality Officer

MINIMUM QUALIFICATION REQUIREMENTS

Education

• Associate's degree in Nursing (or other healthcare-related field) from an accredited college or University.
• Bachelor's or more advanced degree preferred.

Work Experience

• Must have a minimum of two years of recent clinical/nursing experience in a variety of clinical settings.
• 2 or more years of experience in infection control/prevention within the acute care setting strongly preferred
• 1 year or more of experience in Quality/Patient Safety related experience in the acute care setting preferred.
• Experience with CMS Inpatient and Outpatient reporting requirements, processes and programs (via QNet/HARP, etc.) - Preferred
• Experience working the following applications/systems -Preferred:

o Cerner Community Works- (EHR)

o PolicyStat- (Policy/Document/Contract management software)

o Press Ganey High Reliability Platform (HPR)- (Event Reporting Tool)

License/Certification

• Current RN (or other health-related) Tennessee License without restrictions
• Basic Life Support (BLS). (May be obtained within 6 months of hire)
• Certification in Infection Control (CIC) - Strongly Preferred
• CPPS and/or CPHQ- Preferred

CORE COMPETENCIES

SKILLS

• Leadership
• Customer Service
• Effective Communication
• Organization Relations
• Business Acumen
• Diversity and Inclusion
• Crisis Reduction/Critical Thinking

KNOWLEDGE

• Studer Leadership Principles
• Healthcare Laws and Regulatory Agency Standards
• Conflict Resolution/Change Management
• Human Resources/Employment Laws
• Data Management/Synthesizing
• Information Technology

ABILITIES

• The ability to effectively lead others in achieving essential duties
• The ability to effectively converse and actively listen to others concerning HMC matters

BEHAVIOR

• Core Values/Standards of Conduct
• AIDET/Organizational Expectations
• Abuse and Neglect of Adult Patient
• Abuse and Neglect of Pediatric Patient
• Acute Coronary Syndrome/Chest Pain Protocols
• Biohazard Waste
• CC Hand Hygiene

JOB SPECIFIC CORE COMPETENCIES

Department Specific Patient Specialty Area

• Demonstrated Leadership skills.
• Strong teaching/instruction abilities and excellent written and verbal communication skills.
• Demonstrable knowledge of the basic principles of epidemiology and infectious disease.
• Ability to establish good rapport and working relationships with personnel and Medical Staff that allows for effective lines of communication regarding patient or staff safety
• Knowledge of Employee Health concepts and processes.
• Understanding of healthcare-associated infection definitions, chart review, functional understanding of sterilization, disinfection, and sanitation principles.
• Basic understanding and use of microbiology and epidemiology principles, statistical presentation, outbreak investigation techniques, and computer use.
• Adult teaching techniques, clear oral and written communication skills, and policy management.
• Working knowledge of: OSHA/TOSHA standards, including Bloodborne Pathogen Standards; Tuberculosis protection strategies, DNV Accreditation Standards; State (TN), CMS, NHSN(CDC), TennIIS, and other laws and regulations related to Infection Control/Prevention and reporting requirements.
• Strong analytical and problem-solving skills
• Proficiency in data analysis and reporting
• Ability to organize and work effectively and independently and manage competing priorities.
• Demonstrated skills in internal audit and document management.
• Working knowledge of CMS Inpatient and Outpatient reporting requirements, processes, and programs (via QNet/HARP, etc.)

ESSENTIAL FUNCTIONS

In collaboration with the Chief Quality Officer, the Infection Preventionist/Quality Coordinator supports and acts as a resource to Administration, Medical Staff, and all hospital services in supporting our facility's efforts and programs in the areas of Infection Control/Prevention, Quality, and Safety.

Identifies and monitors specified hospital associated infections, performs targeted surveillance, outbreak investigations, and ad hoc projects as defined by the Infection Control/Prevention Committee, Hospital Epidemiologist and the Board of Trustees.

Participates in performance improvement projects related in communicable diseases and

emerging pathogens within the facility

Collects, monitors, and maintains records and data pertinent to surveillance, via computer

support (utilizing Centers for Disease Control (CDC) infection criteria, documentation and

investigation techniques.

Reports surveillance, investigations, and projects as defined above to the appropriate committees,

Administrative staff, and supervisors/managers.

Makes rounds of hospital units for the purpose of evaluating the care environment, monitoring of infection control practices/strategies, and other related patient care issues

Assesses IC safety in infection control risk assessments (ICRA) for construction and renovation projects, approves single-phase projects, and collaborates with hospital leaders and other stakeholders for requirements and approvals. Rounds construction projects to assess ICRA compliance, escalates issues for rapid correction.

Assists the hospital Medical Staff Leaders as necessary, for example:

investigation of possible communicable disease exposures among health care workers,

patients, and/or visitors; tracing the possible sources of infection or transmission of microorganisms within the hospital, investigation of clusters or outbreaks of infections or colonization.

Makes recommendations utilizing professional guidelines (CDC, CMS, OSHA, etc.) to comply with regulatory and accrediting agencies such as federal, state, and local health agencies, and the DNV of Accreditation of Health Care Organization.

Develops and updates policies, practices, and the Infection Control/Prevention Plan to reflect regulatory changes and evidence-based practice.

Attends all meetings of the Infection Control/Prevention Committee and participates in other committees assigned by the Chief Quality Officer and/or Executive Leaders.

Acts as department liaison for Infection Control/Prevention and as a consultant for the facility to integrate Infection Control/Prevention activities throughout the facility. Assists in planning with other departments and personnel to reduce the risk of disease transmission and improved infection control practices.

Collaborates with the appropriate representatives of other disciplines and agencies concerned with patient services to provide coordinated services to patients for the improvement of overall

patient care.

In-service of all new employees during orientation programs and continuing education

programs regarding Infection Control principles, strategies, policies, and procedures.

Responsible for leading, coordinating, and maintaining the facility-wide programs related to Infection Control/Prevention and Employee Health.

Performs concurrent reviews of specific medical records for Infection control/prevention, quality, and/or safety improvement activities.

Provides surveillance throughout the facility to identify actual and/or potential infection risks.

Investigates and records data concerning infections (HAIs and others), communicable diseases, and quality of care/patient safety concerns.

Performs concurrent monitoring of patient records as indicated related to job duties and scope of responsibility.

Conducts regular assessments of the facility to identify and mitigate potential infection risks.

Trains staff on proper infection control techniques and protocols.

Monitors and reports on the incidence and trends of infections and other healthcare-related events.

Collaborates with other healthcare professionals to develop and implement infection control/prevention strategies and programs.

Stays up to date with current infection control practices and regulations.

Provides guidance, education and support to providers and other care team members in educating patients and families on infection control/prevention measures

Manages and ensures submission of all Infection prevention, CMS Inpatient and Outpatient reporting requirements, processes, and other external (local, regional, state, and national) reporting programs (via QNet/HARP, NHSN, etc.)

OTHER DUTIES

Assists with the abstraction of patient records to meet CMS Quality Measures.

Performs other duties and special project work as required.

PHYSICAL DEMANDS

Exposure to blood and body fluids and to mechanical, electrical, and chemical hazards.

Lifting/carrying up to 15 lbs.

Prolonged periods of sitting, standing, and walking

Must be able to see with corrective eyewear

Must be able to hear clearly with assistance

May be exposed to infectious and contagious diseases

Able to handle emergencies and/or crises

May be required to wear protective equipment as necessary

Transferring, repositioning patients.

Reaching, stooping, bending, kneeling, and crouching

Ability to perform effectively in a stressful and fast-paced environment.

Ability to pass all required health and other screening tests including random and reasonable suspicion drug screens.

PHYSICAL ABILITIES AND REQUIREMENTS

Activity

Occasionally (1-33%)

Frequently (34% to 66%)

Continuously (67% to 100%)

Sitting

X

Walking

X

Standing

X

Bending

X

Squatting

X

Climbing

X

Kneeling

X

Twisting

X

Lifting

X

Carrying

X

Pushing

X