Performance Improvement & Infection Prevention Program Manager
About The Position
The Performance Improvement & Infection Control Program Manager works with the ASC staff, leadership and medical staff to ensure the facility is optimized to improve outcomes and efficiencies, increase capacity, minimize risk, and provide safe, timely, cost-effective, compassionate, coordinated, patient and family centered care, while ensuring compliance with Shriners Children’s local, state and federal regulations and requirements, as well as ethical practices. This role also contributes to the overall strategic vision of the infection prevention and control program. This includes identifying, investigating, monitoring and reporting healthcare-associated infections, as well as system-wide infection prevention initiatives that impact all business units within the facility. This role acts as the site subject matter expert in infection prevention, who collaborates with teams and individuals to create infection prevention strategies, provide feedback, and sustain prevention measures.
Requirements
- Bachelor in Healthcare
Nice To Haves
- 2 years in performance improvement/quality/infection prevention
- CPHQ/AIPC Certification
Responsibilities
- Lead and manage the organization's quality, performance improvement, patient safety, and infection prevention programs, ensuring compliance with regulatory, accreditation, and organizational standards.
- Develop, implement, and monitor policies, procedures, and performance improvement initiatives that promote high-quality patient care, safety, and operational excellence.
- Serve as a subject matter expert and resource for staff and leadership on quality improvement methodologies, infection prevention practices, risk management, and patient safety strategies.
- Oversee infection prevention activities, including surveillance, investigations, reporting, staff education, outbreak response, and implementation of evidence-based infection control practices.
- Monitor healthcare-associated infections, review microbiology and surveillance data, and identify opportunities to reduce infection risks and improve outcomes.
- Ensure compliance with federal, state, and accreditation requirements, including CMS, The Joint Commission, CDPH, and mandatory reporting obligations.
- Coordinate accreditation readiness activities, mock surveys, regulatory reviews, corrective action plans, and licensing support.
- Investigate incident reports, patient complaints, grievances, and safety events, ensuring timely resolution, documentation, and corrective actions.
- Lead patient safety initiatives, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and culture-of-safety programs.
- Collaborate with multidisciplinary teams to improve clinical quality, patient satisfaction, environmental safety, and risk reduction efforts.
- Educate and mentor staff on quality, safety, infection prevention, and performance improvement processes while fostering a culture of continuous improvement and accountability.
- Ensure organizational compliance with ADA, disability regulations, and other applicable healthcare laws and standards.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
