Job Description Summary

Under the leadership of the Senior Vice President and Chief Quality and Safety Officer (CQSO) the Director of Infection Prevention and Control is responsible for overseeing system-wide processes for evaluating, managing and preventing infection risks to patients and employees through the implementation of national best practices for infection prevention and control. The Director is accountable for ensuring program congruence and compliance with standards and regulations set forth by The Joint Commission (TJC), Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), and Department of Public Health (DPH)

Job Description

Principle Duties

• Responsible for the ongoing development and timely implementation of evidence-based infection prevention practices across South Shore Health system of care.
• Develops system-wide infection prevention and control goals and supporting operating plan that is specific, measurable, achievable and relevant, working collaboratively with key stakeholders in establishing appropriate targets, timelines for success.
• Performs annual risk assessment of clinical service areas taking into account populations served, care and treatment provided, and analysis of infection prevention and control (IPC) data and surveillance activities. Uses risk analysis information and ongoing surveillance to drive continuous IPC performance improvement.
• Works closely with Quality team and clinical service line leaders to establish processes for ongoing monitoring, trending and evaluation of performance improvement efforts to meet established targets and benchmarks.
• Works collaboratively with IPC Team and Clinical Leaders to develop, maintain, revise and support infection prevention and control policies and procedures ensuring compliance with national and local professional and regulatory standards and guidelines (CDC, OSHA, APIC, TJC, DPH).
• Responsible for ongoing monitoring of environmental cleanliness and compliance of precaution procedures working closely with Safety/Hazards Surveillance group. Directs review and additional inspections where necessary.
• Monitors antimicrobial susceptibly resistance trend studies. Identifies trends, resistance patterns and clusters of infections with same organ when indicated
• Identified risk or potential risk of communicable disease or spread of infection, notifying Infection Prevention Clinical Leader and SVP/Chief Quality and Safety Officer immediately when problem is identified. Collaborates with local/state authorities as needed

Qualifications

Education/Certification/Licensure

• Bachelor of Science in Nursing (Required) from an accredited school
• Master's degree in Nursing, Public Health or Epidemiology (Preferred)
• RN licensure (Required)
  • Certification in Infection Prevention and Control (CIC) (Required)
  • Working knowledge of field of infection control of epidemiology, OSHA standards, identification of pathogens, antibiotic susceptibility testing
  • APIC membership
• 5 years demonstrated competence and experience in Infection Prevention and Control, infectious disease or epidemiology experience in a health care setting
• Previous supervisory/management experience required.
• Previous experience in managing at health system level, strongly encouraged

• Responsible for the development of system-level education that is congruent with professional standards and guidelines. Partners with Clinical Nurse Educators in educating staff and ensuring relevant competencies.
• Participates in staff and departmental rounding and participates in service recovery efforts.
• Utilizes appropriate resources to provide consultation, education, and information services as needed or requested across the organization.
• Oversees coordination and validation of data for submission to National Healthcare Safety Network (NHSN) per state and CMS requirements.
• Recognizes, investigates, documents, and communicates findings of real or potential IPC issues, developing and implementing action plans and follow-up reports within established timeframes.
• Participates in shared governance that supports IPC engagement in organization-wide project teams and committees. Serves as project/committee chair as needed.
• Serves as member of Product Evaluation and Standardization Committee to ensure identification of new products to reduce injury and transmission of microorganisms. Works collaboratively with designated departments to ensure appropriate communication of product changes and enhancements.
• Maintains professional licensure and knowledge of professional practice. Through goal-setting and performance review process, works with staff to develop opportunities for professional development.
• Supports, maintains and promotes organizational culture of safety and reliability. Serves as role model for accountable leadership, demonstrating and promulgating SSH ASPECTS of caring, experience standards.
• Represents Infection Prevention and Control through participation in professional activities as evidenced by attendance at meetings of professional organizations and regional learning collaboratives.
• Participates in Emerging Infectious Disease Committee and facilitates/leads other Infection Prevention Committees as directed