Primary Function: Under the Direction of the Director, Quality, supports the facilitation of the Hospital’s Quality/Patient Safety plans, Additionally, this position is responsible for the facility infection prevention and control program (IPCP), which is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Essential Duties and Responsibilities: 1. Supports the analysis of quality, patient safety and infection prevention data. 2. Serves as subject matter expert to Hospital, physician, ancillary and operations leaders and staff in the development and implementation of strategies to achieve optimal results; 3. Mentors and coaches unit and department directors/managers in infection prevention, quality and patient safety goals as well as contributes to the development of unit based action plans that translate into positive patient outcomes; 4. Analyzes facility specific results to identify opportunities for risk reduction and the development of successful action plans; 5. Complies with the reportable disease requirements of the County and/or State Health Department and any data submission requirements of NHSN. 6. Provides infection control surveillance applying epidemiologic principles and statistical methods, including risk stratification. 7. Analyzes trends and risk factors and designs and evaluates hospital infection prevention and control strategies. 8. Coordinates with federal, state and local emergency preparedness and health authorities to address communicable disease threats, bioterrorism, and outbreaks. 9. Communicates and collaborates with the antibiotic stewardship program. 10. Serves as an active member on various Hospital councils and committees to provide insights relating to the development of ongoing quality initiatives; 11. Supports efforts to maintain perpetual readiness for ACHC, PA DOH, and CMS accreditation and licensing surveys; 12. In the absence of the Director of Quality Management a. Provides continuous, Hospital-wide accountability for all quality and risk issues; b. Communicates Sentinel, critical or reportable events as appropriate, completes root cause analysis, and communicates information, lessons learned and findings to key Hospital/community stakeholders; 13. Maintains current knowledge of ACHC and PA licensing standards. 14. Oversight of the IPCP, which includes, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. 15. Collaborate with the facility leadership and the medical director to develop, implement, and evaluate the annual infection prevention goals and action plan 16. Establish a Hospital-wide system for the prevention, identification, investigation, and control of infections, including surveillance designed to identify possible communicable diseases or infections before they spread. 17. Collaborate with Nurse leadership and education to assess the need for, develop, and present IPCP in-service education for individual departments, general orientation, and annual review as needed; education includes but is not limited to: a. Hand hygiene b. Cleaning, disinfection, and sterilization c. Specific direct and indirect care settings d. Therapeutic and diagnostic procedures and devices e. Use of isolation/barrier precautions when indicated f. Resident placement, transfer, and discharge g. Environmental hazards h. Use of patient care products and medical equipment i. Hospital immunization programs 18. Assess the need for, develop, review and implementation of written policies and procedures for infection control, including those for standard precautions and for transmission-based precautions. 19. Be accountable for surveillance of healthcare-acquired infections. 20. Maintain current knowledge of federal, state, and local regulations and ensure that the facility leaders are informed of appropriate issues; understand and comply with infection control, safety, and OSHA procedures and regulations |