Job Summary
This position promotes high reliability in clinical performance and patient safety through assessment, facilitation and prioritization of improvement activities, overseeing performance improvement projects and ensuring successful clinical project implementation at operating entities. This position additionally has oversight and direction of the infection prevention program for all departments throughout a facility or ambulatory setting, including surveillance, infection prevention and control measures, and education for employees. The position works closely with both system and operating entities to improve quality, infection prevention, patient safety and outcomes of clinical care. All work processed by the team member is considered confidential and protected from discovery, pursuant to state statutes. Essential Functions -
Responsible for oversight and assessment of clinical performance data, infection prevention data, and care delivery practices. Collaborates with administrators, physicians, clinical leaders and staff to identify improvement opportunities utilizing quantitative techniques, knowledge of health care operations and systems thinking. Obtains and uses literature, evidence-based practice and benchmark data whenever possible. -
Conducts focused surveillance for healthcare-associated infections (HAIs), detects and records HAIs on a systematic and current basis, analyzes HAIs and prepares reports for the Infection Control Committee of the facility or ambulatory setting. Reports communicable diseases as required by regulation. -
Improves clinical performance identifies causes of variation, serves as a subject matter expert and supports implementation of systems and processes to facilitate effective clinical practice. Leverages results from clinical performance, infection prevention, peer review, regulatory, patient safety and others to align performance improvement opportunities with system and local teams. -
Facilitates prioritization of improvement activities with system and entity leadership, based on current risk assessment and performance. Conducts collection, aggregation and analysis of data, i.e. clinical performance, surveillance, etc. Initiates epidemiological investigations of significant clusters of infections and single cases of unusual infection. Coordination and dissemination of information to support administrative and clinical decision making. Collaborates with the appropriate process owner(s) to identify opportunities for improvement. -
Manages and coaches performance improvement activities and oversees projects in collaboration with project leaders and administrators. Serves as a subject matter expert and/or facilitates improvement teams to plan, implement, and coordinate entity activities to maximize clinical and operational outcomes. Participates on improvement teams, guiding teams on system defined improvement methodologies and processes. -
Reviews and assists with implementation of policies, procedures and guidelines as they relate to infection prevention. Conducts infection prevention education and in-service programs to departments, including orientation for new employees. Conducts construction, renovation, environmental, and infection prevention rounds, ensuring compliance with system policy and national and/or professional standards for a safe environment. -
Achieves and maintains professional competencies in assessment, performance improvement, surveillance, infection prevention, change/project management, and patient safety. Competency and expertise are obtained through independent study, internal development courses, attending education workshops, reviewing professional publications, establishing personal networks, board certification, and participating in professional organizations. Serves as a consultant and subject matter expert for physicians, nurses, department managers, supervisors, and other professional and non- professional staff members. Minimum Qualifications
Requires Bachelors degree or equivalent in nursing or other healthcare related field.
RN license in state worked OR a clinical background with current license/certification or equivalent experience.
Must have a proficiency level typically attained with five years experience in Quality Management/Performance Improvement. Requires at least two years management experience or demonstrated leadership abilities through successful large scale projects. Must possess demonstrated flexibility in responding to the needs of multiple constituencies with a service-oriented philosophy. Demonstrated ability to lead and facilitate multi-disciplinary teams. Must possess demonstrated skill in problem analysis, project management, conflict resolution and oral and written presentations. Requires ability to balance and manage multiple projects.
Preferred Qualifications
BSN/Masters degree in nursing or Masters in other healthcare related field. Association for Practitioners in Infection Control (APIC) training course or equivalent. Certifications: CIC, CPHQ, CPPS or other relevant certifications. Computer skills, research and basic statistical knowledge is preferred.
Additional related education and/or experience preferred.
|
