Director, Infection Prevention

Hackensack Meridian Health•Holmdel Township, NJ

About The Position

The Director of Infection Prevention, in conjunction with the Hospital Epidemiologist, Regional Chief Quality Officer, Medical Director, Quality and System Improvement, and HMH VP of Infection Prevention and Control oversees the development, implementation and management of an Infection Prevention program that minimizes infectious risk to patients, families and Team Members and complies with current requirements of regulatory, government and accrediting/licensing agencies and organizational policies and procedures. Duties include analysis, interpretation and reporting of surveillance data; designing, implementing and leading organizational performance improvement initiatives, evaluating the effectiveness of the Infection Prevention program and overseeing outbreak investigations and educational programs for Team Members (TMs) and patients.

Requirements

Minimum 5 years of experience in clinical/patient care services or relevant health care position
B.S. Degree in Nursing, Microbiology, Public Health, Medical Technology, Health Care Administration or related field required.
Minimum 3 years of experience in Infection Prevention
Certified in Infection Control.

Nice To Haves

Analytical Problem solving
Collaboration
Strong oral and written communication skills
Ability to implement evidence-based guidelines
Conflict resolution
Program and project management
Expertise in data collection and analysis, report writing, and data presentation
Leadership
Familiar with software technologies (e.g. Excel, MS Word, NHSN, etc)

Responsibilities

Develops, implements, and evaluates the organizational infection prevention program.
Conducts an annual risk assessment and develops annual Infection Prevention plan based on population(s) served, services provided, and analysis of surveillance data.
Develops initiatives and interventions to successfully meet Network and Hospital level infection prevention goals.
Communicates infection prevention information and data to Infection Control Committee, administrative/medical/nursing leadership and other committees as assigned.
Analyzes and identifies any trends in infection prevention data and reports in an appropriate timeframe.
Develops and provides timely, actionable feedback and reports to clinical, administrative and support staff on all Infection Prevention initiatives.
Oversees the surveillance for hospital-acquired infections and ensures compliance with CDCs NHSN definitions and CMS regulations for participation as well as reporting requirements to the State and local health departments.
Manages the NHSN database for accuracy, analytics and reporting.
Oversees documentation and reporting communicable diseases as defined by federal, state, and local levels.
Evaluates and manages investigations of infection related outbreaks, implements appropriate control measures and monitors effectiveness of control measures.
Develop, interpret, and assist with implementation and education of infection prevention policies and procedures.
Reviews and maintains all department policies that relate to infection control annually.
Oversees standards, practices and compliance involving sterilization, disinfection, construction and sanitation as they pertain to Infection Prevention.
Oversees Infection Prevention and Control Construction Risk Assessments (ICRAs) for construction, renovation and maintenance projects and monitors compliance with infection prevention recommendations to reduce risk of communicable disease exposures to patients and TMs.
Participates and ensures team members round on units/departments to observe compliance with infection prevention policies/procedures and provide just in time coaching (e.g. Disinfection processes, hand hygiene and PPE).
Acts as a liaison between the community and/or public health department for potential or actual communicable disease issues.
Collaborates with Value Analysis Committee in establishing infection control criteria for medical/surgical products and assists in the evaluation of new products.
Performs other related duties as assigned.
Assures 24/7 coverage of department.
May be required to work or be on call weekends and/or second shift based on department needs.
Develops written education and information documents about infection prevention and control.
Assists in the development of employee, volunteer and clinical staff orientation and continuing education programs regarding infection prevention. Including but not limited to communicable diseases, microbiological hazards, blood borne pathogens, tuberculosis and regulatory agency standards.
Assess and address learning needs of those served.
Create education goals, objectives, and strategies using learning principles and available educational tools and technology.
Evaluate the effectiveness of educational programs and learner outcomes.
Ensure compliance with regulatory and mandatory reporting requirements at the local, state and federal levels.
Facilitate compliance with regulatory and accreditation standards (e.g. NHSN, Joint Commission, etc.).
Assists the organization evaluate and maintain readiness for state, federal, and accrediting agency surveys.
Maintains an updated knowledge of all infection prevention regulatory and accreditation standards per CMS, NJ DOH, Joint Commission, OSHA, CDC.
Utilizes PI methodology and High Reliability principles as a means of enacting change.
Defines the scope of the project and selects appropriate PI tools to aid in efficiency, reliability, effectiveness and ensure sustainability of the initiative.
Ensures that customer needs and expectations are considered in the development of and continuous improvement of processes, products, and services.
Monitors and analyzes, using appropriate analytical tools and statistical process control, process and outcome measures to evaluate the effectiveness and sustainability.
Demonstrates use of appropriate methodologies to identify improvement opportunities and use of rapid cycle improvement tools (i.e. PDSA, FMEA, reliability science, bundle science, process flows).
Participate in PI committees, teams and initiatives as indicated.
Participate in the development/review of occupational health policies and procedure related to Infection Prevention.
Assess risk of occupational exposures to infectious disease.
Assist with rates/trends of occupational exposure if indicated.
Assist with immunization and screening programs if indicated.
Collaborate with team member work restrictions and recommendations related to communicable diseases or following an exposure.
Collaborates with Occupational Health for exposures to communicable diseases and Team Member safety.
Directly supervises and manages Infection Prevention team members.
Provides introductory and annual performance appraisals of infection prevention personnel.
Identifies and provides learning opportunities and career advancement.
Coaches and counsels team members and institutes appropriate corrective action.
Responsible to hire and coordinates orientation of new team members.
Maintains documentation of team member compliance with required programs.
Pursue professional growth and development of required knowledge and skills.
Maintain certification and licensure requirements if indicated.
Establish at least 1 professional goal per year.
Advocate for patient safety, high reliability practices, team member safety, and safe practices.
Participate in an infection prevention professional organization/association (e.g. APIC).
Attends and demonstrates compliance with required programs.
Works closely with all clinical and non-clinical team members in the development and implementation of programs directed at prevention of health care associated infections and infection prevention.
Provides coaching and hands-on support as needed.
Consult and collaborate, as needed, with local, state, and federal public health officials, and community health organizations.
Involve multidisciplinary teams to ensure changes are vetted by all stakeholder groups.
Participate in Network meetings/projects.
Participate/Support emergency preparedness to ensure organizational readiness for emerging infectious diseases, bioterror and influenza.
Utilize principles of influence, leadership, and change management.
Bring enthusiasm, creativity and innovation to practice.
Work collaboratively with others, providing direction when necessary.
Readily share knowledge and expertise.
Contribute to the development of less-experience healthcare providers through education and mentorship.
Prepare and deliver infection prevention presentations to external groups.
Evaluate (critically) research and evidence-based practices and incorporate appropriate findings into routine practice.
Integrate evidence-based practices into policies, guidelines, protocols and educational strategies.
Identify barriers for implementation and develop strategies to minimize or remove barriers.
Implement strategies to sustain efforts such as audit tools and meaningful feedback.
Be familiar with infection prevention software and other technology (e.g. NHSN, CDRSS).
Collaborate with IT and Data Science to create meaningful electronic reports to enhance infection prevention initiatives.
Consider the financial/safety implications and clinical outcomes when making recommendations, evaluating technology and products, and developing policies and procedures.
Use a systematic approach to evaluate costs, benefits, and efficacy.
Incorporate fiscal assessments into program evaluations and/or reports.
Develop and maintain departmental budget.