Director of Infection Prevention, Infection Control Unit

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

• Bachelor's in Nursing, Microbiology, Public Health or related field required
• Master's in Nursing, Microbiology, Public Health, Epidemiology or related field preferred

1. Valid California RN License
2. Board Certified in Infection Prevention and Control (C.I.C) required on hire or within one year of hire
3. Valid Fire Card required on hire or within 30 days of hire
4. Completion of basic training course in infection control

• 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.

1. Planning and Organization of Infection Prevention/ Control Program (IP/IC) Activities

1. 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.
2. 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.
3. Reviews/ authors Infection Prevention/Control policies as needed.
4. 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.
5. Prioritizes IP/IC goals based on risks of Hospital-Associated Infections (HAIs) within our hospital.
6. Prepares monthly/ quarterly reports of surveillance data for presentation to the Infection Control meeting and reports findings to the various Medical Staff Committees.
7. Prepares surveillance reports / investigations to appropriate Performance Improvement (PI) task forces and departments.
8. Reports surveillance findings and recommendations of surveillance data to the staff as necessary.
9. Collaborates with all Department Directors/ Mangers/ Supervisors and Medical Directors in implementing aspects of the Infection Prevention/Control Program.
10. Collaborates with the Occupational Health Department Manager in investigating and helping to manage employee exposure to communicable and infectious diseases.

1. Designs, coordinates, compiles, and conducts surveillance and epidemiological investigations and interprets/ analyzes data.
1. Conducts infection surveillance on a concurrent and /or retrospective basis for the purpose of identifying hospital -associated infections.
2. Participates in the development of plans for decreasing / preventing hospital- associated infections or occurrences.
3. Designs or adopts the National Safety Network (NHSN) surveillance plans.
4. Coordinates and conducts environmental surveillance to evaluate patient care environment for infection control and safety.
5. 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.
6. Reviews laboratory reports daily to identify hospital -associated infections, identify reportable diseases, and to assess potential outbreak situation.
7. Collaborates with Microbiology staff and the clinical pharmacist (if appropriate) on significant findings or unusual occurrences.
8. Recognizes serious reportable events and epidemiologically significant organisms that may require immediate investigation.
9. 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.
10. 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.
11. Analyzes surveillance data and data on special projects/studies for trends, patterns, or clusters of infections and prepares reports to committees.
12. Organizes and maintains an electronic file of all data in IP/IC shared file.
13. 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.

1. Communication
1. Collects and communicates significant Infection Control information to appropriate committees and staff.
2. Communicates and collaborates (per IP/IC and hospital policies) with hospital departments to provide information on infection control practices.
3. Communicates information to regulatory agencies as required/needed.
2. Consultation
1. Provides Infection Prevention/Control/Epidemiology consultation to hospital staff, and physicians per request or as deemed necessary by IP/IC staff.
2. Serves as resource on IP/IC risk assessment and prevention and control strategies
3. Education
1. Performs educational needs assessment of the hospital staff pertaining to IP/IC.
2. Provides IP/IC classes to the New Employee Orientation Program, RN Residency Program and department in-services.
3. Evaluates the effectiveness of the IP/IC education programs.
4. Provides classes on Influenza, TB, or significant or unusual disease or organism as necessary according to current needs and as required by regulatory agencies.
5. Provides education materials to staff, patients, relatives or patient designees.
6. Attends education conferences, in-services, workshops, etc. to remain current in infection prevention and control practices and to disseminate pertinent information to hospital staff.
7. Maintains a current membership in APIC and AOHP and attends meetings. Participates in community education when necessary.