JOB SUMMARY:
The Director of Infection Prevention is a professional who develops, implements, and monitors the hospital-wide Infection Prevention/Control Program (IP/IC).
EXPERIENCE/QUALIFICATIONS:
- Minimum 5 years in an acute health care setting
- Ability to develop policies and procedures
- Ability to teach and evaluate clinical performance
- Ability to provide current educational programs in Infection Prevention and Control topics
EDUCATION:
- Bachelor’s in Nursing, Microbiology, Public Health or related field required
- Master’s in Nursing, Microbiology, Public Health, Epidemiology or related field preferred
LICENSURES/CERTIFICATION:
- Valid California RN License
- Board Certified in Infection Prevention and Control (C.I.C) required on hire or within one year of hire
- Valid Fire Card required on hire or within 30 days of hire
- Completion of basic training course in infection control
MUST HAVES:
- All required licensures, certifications, mandatory education; along with annual occupational health screenings must be completed prior to the expiration date or by the end of the month in which they are due. Reference the Educational Requirements: Must Haves, Mandatory and Unit Based policy (in electronic policy management system) for the specific requirements for this position.
DUTIES AND RESPONSIBILITIES (These are the essential job functions for this position. The essential functions of this job include, but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential function of this job without imposing significant risk of substantial harm to the health or safety of themselves or others):
1. Planning and Organization of Infection Prevention/ Control Program (IP/IC) Activities
- Coordinates functions/ activities of the hospital-wide Infection Prevention/Control Program as defined by the Senior Vice President, Chief Medical Officer based on regulatory requirements.
- Facilitates compliance with local, state and federal rules, recommendations, and regulations (Centers for Medicare and Medicaid (CMS), National Integrated Accreditation for Healthcare Organizations (NIAHP-1, DNV), Standards of Practice. Occupational Safety & Health Administration (OSHA), Association for Professionals in Infection Control & Epidemiology (APIC), Association of Occupational Health Professionals (AOHP), Centers for Disease Control & Prevention (CDC), hospital policies, and Medical Staff Bylaws.
- Reviews/ authors Infection Prevention/Control policies as needed.
- Prepares/authors the annual Infection Prevention/Control Program and Plan to include strategies to accomplish goals, outcome measures, and projects in collaboration with other stakeholders.
- Prioritizes IP/IC goals based on risks of Hospital-Associated Infections (HAIs) within our hospital.
- Prepares monthly/ quarterly reports of surveillance data for presentation to the Infection Control meeting and reports findings to the various Medical Staff Committees.
- Prepares surveillance reports / investigations to appropriate Performance Improvement (PI) task forces and departments.
- Reports surveillance findings and recommendations of surveillance data to the staff as necessary.
- Collaborates with all Department Directors/ Mangers/ Supervisors and Medical Directors in implementing aspects of the Infection Prevention/Control Program.
- Collaborates with the Occupational Health Department Manager in investigating and helping to manage employee exposure to communicable and infectious diseases.
- Designs, coordinates, compiles, and conducts surveillance and epidemiological investigations and interprets/ analyzes data.
- Conducts infection surveillance on a concurrent and /or retrospective basis for the purpose of identifying hospital –associated infections.
- Participates in the development of plans for decreasing / preventing hospital- associated infections or occurrences.
- Designs or adopts the National Safety Network (NHSN) surveillance plans.
- Coordinates and conducts environmental surveillance to evaluate patient care environment for infection control and safety.
- Makes rounds for purposes of case finding, supervision of infection prevention/control practices, environmental sanitation, and serve as a resource for the staff, patients, visitors, and others needing information on infection control.
- Reviews laboratory reports daily to identify hospital -associated infections, identify reportable diseases, and to assess potential outbreak situation.
- Collaborates with Microbiology staff and the clinical pharmacist (if appropriate) on significant findings or unusual occurrences.
- Recognizes serious reportable events and epidemiologically significant organisms that may require immediate investigation.
- Reviews patient medical records using the actual chart or the Meditech/Webmedx for patient assessment, data collection for surveillance purposes, to differentiate community – acquired from hospital- associated infections.
- Collects, compiles and identifies data on all required surveillance by the National Healthcare Safety Network (NHSN), the California Department Public Health (CDPH), and by the hospital.
- Analyzes surveillance data and data on special projects/studies for trends, patterns, or clusters of infections and prepares reports to committees.
- Organizes and maintains an electronic file of all data in IP/IC shared file.
- Prepares an annual report and evaluation of the Infection Prevention/Control Program/ IP/IC activities with the Chief Medical Officer and the Infection Prevention chairman to demonstrate the effectiveness of the Infection Prevention/Control program.
- Communication
- Collects and communicates significant Infection Control information to appropriate committees and staff.
- Communicates and collaborates (per IP/IC and hospital policies) with hospital departments to provide information on infection control practices.
- Communicates information to regulatory agencies as required/needed.
- Consultation
- Provides Infection Prevention/Control/Epidemiology consultation to hospital staff, and physicians per request or as deemed necessary by IP/IC staff.
- Serves as resource on IP/IC risk assessment and prevention and control strategies
- Education
- Performs educational needs assessment of the hospital staff pertaining to IP/IC.
- Provides IP/IC classes to the New Employee Orientation Program, RN Residency Program and department in-services.
- Evaluates the effectiveness of the IP/IC education programs.
- Provides classes on Influenza, TB, or significant or unusual disease or organism as necessary according to current needs and as required by regulatory agencies.
- Provides education materials to staff, patients, relatives or patient designees.
- Attends education conferences, in-services, workshops, etc. to remain current in infection prevention and control practices and to disseminate pertinent information to hospital staff.
- Maintains a current membership in APIC and AOHP and attends meetings. Participates in community education when necessary.
- Community Interface and Communicable Disease Reporting
- Acts as the hospital liaison with the local, state and federal agencies following state mandated reporting guidelines.
- Reports surveillance data to NHSN/ CDPH and public reporting requirements.
- Coordinates with Plant Operations/Engineering Department on construction activities in the hospital.
- Outbreak Investigation and Management
- Identifies clusters of infections or unusual occurrences using evidence-based processes, analyze data, and offer recommendations to control outbreak or to correct practices.
- Reports outbreaks or unusual occurrences to the appropriate agency.
- Infection Prevention/Control
- Demonstrates current knowledge of Infection Prevention/Control process/ policies/ procedures and acts as a role model for IP/IC practice.
- Recognizes infectious and communicable disease process and initiates appropriate actions.
- Applies the OSHA Bloodborne Pathogens Standard and other current mandates on Infection Prevention/Control.
- Customer Service
- Role models hospital values and behavioral norms to every customer group.
The following job accountabilities are not unique to this particular job but are common to all jobs at VPH:
- Complies with VPH policies and procedures on customer satisfaction and service excellence. Demonstrates professionalism and cultural sensitivity in coordinating activities and communicating with all customers, peers, and the community at large. Conducts self in a professional, respectful and courteous manner during all interactions. Works effectively and collaboratively with others toward common goals.
- Communicates accurately, honestly, supportively and in a timely manner with department and interdepartmental team members. Demonstrates effective business writing and oral communication skills, handwriting is clear and legible.
- Participates in operational aspects of the department, and maintains/participates in performance improvement activities within the department.
- Participates in all departmental specific training, Environment of Care (injury/illness prevention, fire/life safety, hazardous materials, emergency preparedness, utilities management, medical equipment management, safety and security management), infection control (standard precautions, TB Exposure Control Plan, Bloodborne Pathogen Exposure Control Plan).
- Demonstrates knowledge of and follows safety practices. Understands the importance of safety, including patient safety in the work place. Maintains a safe environment for self and others.
- Actively participates in the Patient Safety Program, including event reporting. Identifies sentinel events/near misses and responds per defined organization processes. Participates in education activities and process implementation. Demonstrates advocacy for the patient/customer and appropriately acknowledges patients, customers and visitors.
- The above statements reflect the essential functions considered necessary to describe the principle content of the job. They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.
WORK ENVIRONMENT:
· Primarily an inside building/office environment, well lighted and ventilated, which may consist of multiple treatment and/or work sites.
· Fast and continuous work pace with variable workload.
· Frequent contact with staff and public under a variety of circumstances. Requires ability to communicate clearly (in English) verbally and in writing for effective communication with other staff members, physicians, vendors, community members, patients and patient families, employees and applicants of all socio-economic levels from a diverse cultural and ethnic population.
· Subject to many interruptions from multiple calls and inquiries and potentially emotional situations involving accidents, injuries, illness and/or death.
· Handles emergency/crisis situations in accordance with Hospital policy.
· Answers phones or pages; may carry a beeper/pager, and/or use a two-way radio.
· Occasional travel may be required.
· Potential risk of exposure to hazards from chemicals (toxic and non-toxic), flammable materials, gas or electrical or radiant energy or equipment with/without moving parts.
PHYSICAL DEMANDS:
Key for Physical Demands
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Continuous
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66 to 100% of the time
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Frequent
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33 to 65% of the time
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Occasional
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0 to 32% of the time
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Patient Care
* Continuous standing/walking and occasional/intermittent sitting.
* Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and shoulder level to handle/operate medical equipment/devices.
* Frequent reaching above shoulder level and overhead.
* Frequent forward bending, twisting, squatting and kneeling; occasional climbing.
* Occasional repositioning and transferring patients weighing up to 200 pounds between bed, chair, and gurney.
* Occasional lifting and carrying equipment weighing up to 25 pounds.
* Occasional/intermittent pushing of gurneys, wheelchairs, bed and other medical equipment over tiled and carpeted surfaces.
* Continuous use of near vision to read medical equipment such as monitoring devices and reading documents and computer screens; hearing and verbal communication to interact with patients, co-workers, and other customers.
Clerical/Administrative Patient Care
* Frequent sitting and standing/walking with frequent position change.
* Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
* Occasional/intermittent reaching at or above shoulder level.
* Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.
* Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.
* Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.
Clerical/Administrative Non-Patient Care
* Frequent/continuous sitting with occasional, intermittent standing/walking.
* Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
* Occasional/intermittent reaching at or above shoulder level.
* Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting and climbing.
* Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.
- Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.
Salary Range: $74.19 to $92.12 per hour