Manager Infection Prevention & Control - Full Time, Frederick Health, Frederick, MD
Frederick Health -
Frederick, MD,
US
Manager Infection Prevention & Control - Full Time
Date Posted: 2024-06-13
Job description
Job Summary
Reporting to the VP of Quality Assurance and patient Experience, the Manager of Infection Prevention and Control is responsible for providing leadership and support across the organization in all aspects of the infection prevention process. In the area of infection prevention and control this position is responsible for supporting executive, administrative and medical staff leadership, as well as clinical and operational staff with initiatives to improve quality, prevent healthcare associated infections and ensure mandatory compliance with infection control, prevention, reporting and education. This includes IPAC activities in both inpatient and ambulatory and offsite areas. The goal of the department is to lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes. This position oversees and promotes accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation. This also includes supporting Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep staff and providers aware of all regulatory and accreditation standards. This position oversees the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system s public transparency, HSCRC Pay for Performance programs, and penalty programs. This position is responsible for managing/overseeing specific system projects related to infection prevention and control. In addition, he or she is responsible for overseeing and managing Frederick Health s participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System.
The Manager provides administrative direction for the department s operations, budgeting, development of information systems and coordination of information flow. The Manager supports, and is responsible for incorporating into job performance, the Frederick Health mission, vision, core values and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements, and the Frederick Health Standards of Behavior.
Example of Essential Functions
Participates in and provides leadership to the establishment, implementation, and maintenance of the organization s clinical quality improvement strategies, programs, and methods related to regulatory compliance and infection prevention
Develops, implements, and monitors the effectiveness of strategies and plans
Designs and coordinates communication of regulatory and hospital acquired infection improvement activities and outcomes and results to enhance programming
Communicates concepts and issues effectively (written and oral) across all service lines within the organization
Provides quality reports and metrics to stakeholders in an ongoing and ad hoc basis
Identifies appropriate national and state databases for comparison of regulatory and infectious disease data
Able to convert data into actionable information
Coach, train, and develop teams to create processes to consistently achieve best practices that is evidence based
Facilitates problem-solving within and between program areas
Lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes
Manages and promote accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation
Supports Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep system aware of all regulatory and accreditation standards
Manages the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system s public transparency, HSCRC Pay for Performance programs, and penalty programs.
Manages specific system projects related to infection prevention and control.
Manages and validates Frederick Health s data and participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System
Assures the data system for electronically reporting infections and hospital acquired infections or any epidemics function and are accurate
Interpret and apply external regulations and standards in relation to health care delivery the hospital and ambulatory and outpatient setting
Manages projects related to Ebola and other infectious disease epidemic preparedness and those teams associated with those diseases
Manages projects related to the Environment of Care as it relates to regulatory compliance especially those related to patient safety, staff safety and the prevention of infectious disease for the organization
Collaborates with the key leaders of the Environment of Care to assure compliance with TJC, state, CMS, local government and OSHA
Maintains contact with legal counsel and risk management regarding medical-legal matters
Maintains current knowledge of TJC, CMS, ACC national quality indicator guidelines, Magnet and NDNQI and assesses compliance for assigned areas
Executes effective improvement projects through multidisciplinary team collaboration
Assures issues are communicated to appropriate committees or individuals and that issues have timely resolution.
Interacts/interfaces with all members of the medical staff, nursing and ancillary departments to discuss pertinent regulatory issues and follow up of patients
Attends and supports committees as appropriate including the Environment of Care Committee, Quality Coordinating Council, the Patient Safety Committee, and various quality related Nursing Committees
Work collaboratively with the Board, Administration and Leadership
Creates and maintains a positive work environment by being responsible for all aspects of personnel management from recruitment, staff development, create job performance standards, conduct performance evaluations, evaluate workload, promote optimal productivity, team building, identify/provide excellent customer service, resolve staffing issues, counsel personnel and following the process for disciplinary action when warranted
Plans and allocates resources to effectively staff departments and accomplish productivity and quality goals
Plans, evaluates, and improves the efficiency of processes and procedures to enhance speed, quality, efficiency, and results
Formulates business decisions that are financially responsible, accountable, justifiable, and defensible in accordance with organization policies and procedures
Establishes and maintains relevant controls and feedback systems to monitor the operation of the departments
Reviews performance data that includes quality, satisfaction, engagement, and financial reports
Monitors and measures productivity, goal achievement, and overall effectiveness
Participates in the preparation and maintenance of reports necessary to carry out the functions of the areas of responsibility
Prepares periodic reports for management to track goal accomplishment
Manages human resources activities in regards to: recruiting and selection; hiring and termination, training, development, mentoring, counseling, and performance evaluations
Performs other duties as assigned
Required Knowledge, Skills and Abilities
Bachelor s Degree in Nursing or other related field required
Ten years work experience in a healthcare setting required.
CIC certification required.
Team facilitation and experience with hospital accreditation standards and survey process.
Patient Contact
Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:
Performance of job does not require patient contact
Physical Demands:
Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.
Ergonomic Risk Factors:
Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.
Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.
Working Conditions:
Reporting Relationship:
Reports to the VP of Quality Assurance and patient Experience
Reporting to the VP of Quality Assurance and patient Experience, the Manager of Infection Prevention and Control is responsible for providing leadership and support across the organization in all aspects of the infection prevention process. In the area of infection prevention and control this position is responsible for supporting executive, administrative and medical staff leadership, as well as clinical and operational staff with initiatives to improve quality, prevent healthcare associated infections and ensure mandatory compliance with infection control, prevention, reporting and education. This includes IPAC activities in both inpatient and ambulatory and offsite areas. The goal of the department is to lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes. This position oversees and promotes accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation. This also includes supporting Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep staff and providers aware of all regulatory and accreditation standards. This position oversees the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system s public transparency, HSCRC Pay for Performance programs, and penalty programs. This position is responsible for managing/overseeing specific system projects related to infection prevention and control. In addition, he or she is responsible for overseeing and managing Frederick Health s participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System.
The Manager provides administrative direction for the department s operations, budgeting, development of information systems and coordination of information flow. The Manager supports, and is responsible for incorporating into job performance, the Frederick Health mission, vision, core values and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements, and the Frederick Health Standards of Behavior.
Example of Essential Functions
Participates in and provides leadership to the establishment, implementation, and maintenance of the organization s clinical quality improvement strategies, programs, and methods related to regulatory compliance and infection prevention
Develops, implements, and monitors the effectiveness of strategies and plans
Designs and coordinates communication of regulatory and hospital acquired infection improvement activities and outcomes and results to enhance programming
Communicates concepts and issues effectively (written and oral) across all service lines within the organization
Provides quality reports and metrics to stakeholders in an ongoing and ad hoc basis
Identifies appropriate national and state databases for comparison of regulatory and infectious disease data
Able to convert data into actionable information
Coach, train, and develop teams to create processes to consistently achieve best practices that is evidence based
Facilitates problem-solving within and between program areas
Lead prevention activities to minimize the incidence, impact and risk for healthcare associated infections (HAI) for patients, visitors, employees and medical staff using evidenced based state-of-the-art processes
Manages and promote accreditation and regulatory compliance with all relevant infection control and prevention standards and required communicable disease reporting including outbreak investigation
Supports Hospital Leadership with hiring of Infection Preventionists, to ensure that IPs are properly trained and to keep system aware of all regulatory and accreditation standards
Manages the mandatory reporting of infections to CMS, the state, and the local health department; which impacts the system s public transparency, HSCRC Pay for Performance programs, and penalty programs.
Manages specific system projects related to infection prevention and control.
Manages and validates Frederick Health s data and participation in the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) System
Assures the data system for electronically reporting infections and hospital acquired infections or any epidemics function and are accurate
Interpret and apply external regulations and standards in relation to health care delivery the hospital and ambulatory and outpatient setting
Manages projects related to Ebola and other infectious disease epidemic preparedness and those teams associated with those diseases
Manages projects related to the Environment of Care as it relates to regulatory compliance especially those related to patient safety, staff safety and the prevention of infectious disease for the organization
Collaborates with the key leaders of the Environment of Care to assure compliance with TJC, state, CMS, local government and OSHA
Maintains contact with legal counsel and risk management regarding medical-legal matters
Maintains current knowledge of TJC, CMS, ACC national quality indicator guidelines, Magnet and NDNQI and assesses compliance for assigned areas
Executes effective improvement projects through multidisciplinary team collaboration
Assures issues are communicated to appropriate committees or individuals and that issues have timely resolution.
Interacts/interfaces with all members of the medical staff, nursing and ancillary departments to discuss pertinent regulatory issues and follow up of patients
Attends and supports committees as appropriate including the Environment of Care Committee, Quality Coordinating Council, the Patient Safety Committee, and various quality related Nursing Committees
Work collaboratively with the Board, Administration and Leadership
Creates and maintains a positive work environment by being responsible for all aspects of personnel management from recruitment, staff development, create job performance standards, conduct performance evaluations, evaluate workload, promote optimal productivity, team building, identify/provide excellent customer service, resolve staffing issues, counsel personnel and following the process for disciplinary action when warranted
Plans and allocates resources to effectively staff departments and accomplish productivity and quality goals
Plans, evaluates, and improves the efficiency of processes and procedures to enhance speed, quality, efficiency, and results
Formulates business decisions that are financially responsible, accountable, justifiable, and defensible in accordance with organization policies and procedures
Establishes and maintains relevant controls and feedback systems to monitor the operation of the departments
Reviews performance data that includes quality, satisfaction, engagement, and financial reports
Monitors and measures productivity, goal achievement, and overall effectiveness
Participates in the preparation and maintenance of reports necessary to carry out the functions of the areas of responsibility
Prepares periodic reports for management to track goal accomplishment
Manages human resources activities in regards to: recruiting and selection; hiring and termination, training, development, mentoring, counseling, and performance evaluations
Performs other duties as assigned
Required Knowledge, Skills and Abilities
- Knowledge of company policies, and state/federal regulatory and accreditation standards.
- Ability to work with or lead interdisciplinary teams.
- Knowledge of federal, state, joint commission and other regulatory standards
- Ability to build and maintain professional knowledge
- Excellent communications skills both verbally and written.
- Ability to create collaborative working relationships
- Ability to create and maintain a participatory environment.
Bachelor s Degree in Nursing or other related field required
Ten years work experience in a healthcare setting required.
CIC certification required.
Team facilitation and experience with hospital accreditation standards and survey process.
Patient Contact
Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:
Performance of job does not require patient contact
Physical Demands:
Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.
Ergonomic Risk Factors:
Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.
Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.
Working Conditions:
- Bloodborne Pathogens Exposure Risk: Category C NO exposure to blood or body fluids
- Works in well-lighted/ventilated office areas.
- Extended work hours beyond 8 hours per day and 40 hours per week.
Reporting Relationship:
Reports to the VP of Quality Assurance and patient Experience