For the medical center(s) and associated office buildings in an entire Medical Center, directs the management, planning, development, implementation, evaluation/continuous improvement of an infection prevention and control program across entire care continuum. Collaborates with and makes recommendations to Medical Center and facility leadership team to ensure compliance with regulatory agencies and assures facility-wide and departmental policies and procedures that comply with current Regulatory standards. Through strategic planning, expert leadership and consultation, directs the identification and implementation of infection control goals and objectives related to: surveillance, data analysis and reporting, infection prevention and control practices that eliminate potential infection hazard for members, physicians, staff and visitors, appropriate selection and usage of products and equipment related to cleaning, antisepsis, disinfection, and sterilization, facility design and construction. Directs the development and implementation of educational programs designed to reduce or prevent infection. Assures compliance with all mandated regulatory reporting requirements including but not limited to California Department of Public Health (CDPH), Centers for Medicare and Medicaid (CMS). Provides infection prevention and control programs/services that add value and integrated with departmental, facility, Medical Center and organizational business and clinical goals/objectives.
- Upholds our Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.
- Directs the management of the planning, development, implementation, evaluation/improvement of infection prevention and control services/programs that meet or exceed established standards/performance measures for quality, member/patient satisfaction, cost, employee quality of work life, physician/client department satisfaction, clinical outcomes and regulatory compliance.
- Directs infection prevention and control services/programs across the continuum of care (primary, secondary, continuing care) and ensures that services/programs are of uniform and consistent value, quality, performance and cost throughout all departments in a medical center and its associated outpatient/satellite buildings.
- Directs development and implementation of evidence-based interventions designed to reduce/eliminate the risk for Healthcare Associated Infections (HAIs) and/or disease transmission.
- In partnership with the Sterile Processing Director/Manager provides expert leadership and knowledge to assure all sterilization and disinfection processes throughout the Medical Center Service Area are in compliance with all national standards.
- Develops and maintains excellent, collaborative relations with key stakeholders/departments including but not limited to: Employee Health, Nursing, Perioperative, Perinatal, Emergency Services, Urgent Care, and various physician specialties.
- Directs human resources management processes; provides supervision and leadership to Infection Prevention staff; hires, fires, promotes, demotes, manages and evaluates staff performance and development.
- In partnership with Infection Prevention staff and departmental managers develops, monitors and modifies Infection Prevention and Control Program department specific goals/objectives as appropriate.
- Directs the provision/delivery of services/programs which meet identified needs of client departments.
- Directs compliance with applicable regulatory requirements through interpretation of Regulatory Standards, investigation of disease outbreaks and exposures, surveillance and reporting communicable diseases to the CDPH as required.
- Directs the development and management of operating budget, capital expense, and remodel requirements as appropriate, monitors and analyzes financial reports and justifies variances.
- Manages and/or reduces costs.
- Develops and maintains effective communication with administrative/management staff and physicians.
- Acts as the Infection Prevention and Control liaison/consultant for the entire Medical Center and/or delegates appropriate duties.
- Directs surveillance activities and the monitoring, reporting and development of applicable intervention(s) for infection trends (e.g. National/Regional/ Divisional Indicators, Board Report, facility specific indicators, etc.) in the acute and ambulatory settings.
- Directs the development and review of Infection Prevention and Control Standards of Care Policy and Procedure manuals.
- Develops, implements and improves systems, methods, processes to evaluate/improve performance and quality outcomes/measures for infection prevention and control services/programs throughout an entire Medical Center Service Area.
- Together with the Infection Control Committee Chair, initiates and directs research projects and epidemiological investigations of significant clusters of infection or serious communicable disease concern.
- Participates in the preparation and response to emerging infectious disease threats and/or exposures.
- Serves as subject matter expert who assists medical center leadership team in internal or external disaster response/mitigation.
- Provides expert review and consultation for all facility construction/remodels as described in the Organizations Pre-Construction Risk Assessment (PCRA).
- Assume other activities and responsibilities from time to time as directed
- Minimum three (3) years of experience as an Infection Control Professional.
- Minimum three (3) years of experience in an established infection prevention/control program in an acute care hospital including minimum two (2) years of program management/supervisory experience.
- Bachelors degree in Nursing, Science or healthcare related field.
License, Certification, Registration
- Infection Control Certificate
- Ability to demonstrate knowledge of microbiology, laboratory procedures, aseptic technique and epidemiological techniques.
- Demonstrated ability to comprehend and utilize epidemiological/public health data and statistical methods, screen and interpret data results for variations and/or errors.
- Organizational, problem-solving, decision making, conflict resolution, change management and strategic planning skills.
- Function as a liaison person, instructor/communicator, consultant, manager, and program manager.
- Must be able to work in a Labor/Management Partnership environment.
- Demonstrated knowledge/experience in leading performance improvement initiatives preferred.
- Masters degree in public health, epidemiology, environmental health, microbiology or other public health related field.