Quality, Risk, Infection Control Manager

Coalinga Regional Medical Center•Coalinga, CA

33d

About The Position

This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants, and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation. POSITION SUMMARY This position is responsible for establishing and maintaining a quality assurance system that promotes customer satisfaction, risk assessment, and improvement performance of the facility and infection prevention and control. Leads and directs performance/process improvement activities that provide more efficient and streamlined workflow in a hospital environment. Presents results of improvement efforts and ongoing performance measures of clinical processes within the hospital to the management team. They also have participatory responsibility for regulatory body surveys, such as DNV, State Licensing Review, and CMS Validation surveys. Maintains responsibility for all quality and performance improvement activities conducted throughout the hospital. They are responsible for the reporting to various mandated reporting to agencies such as CMS, CDPH, CDC, NHSN, etc.

Requirements

The knowledge and abilities required to perform this function are typically acquired through training and experience equivalent to four (4) years of experience in an acute care hospital setting.
Valid LVN license in California, RN Preferred
Strong organizational, time management, and communication skills.
Familiarity with infection prevention protocols.
2+ years of clinical experience in infection prevention preferred.
Previous experience in an acute care, long-term care, or similar healthcare setting desirable.
Must obtain certification in Infection Prevention and Control (IPC) within 6 months of hire and maintain active certification throughout employment to meet industry standards.
Special/Skills and/or Equipment Used: Demonstrated ability to plan, set, and accomplishes multiple objectives. Attention to detail, exhibit self-direction, high degree of independence, judgment and discretion, teaching ability, effective oral and written communication skills, demonstrated ability to work effectively with others as a team member. Requires the ability to work with highly confidential and sensitive information. Must have analytical and problem solving skills as well as the ability to coordinate and communicate effectively with diverse others including, colleagues, managers, medical staff and be able to teach and develop others. Must be able to prioritize, make decisions and set clear expectations for others. Must possess excellent negotiation skills. Must be computer knowledgeable.

Nice To Haves

Certified Professional in Healthcare Quality is preferred.
Nursing management experience is desirable but not required.

Responsibilities

Develop, implement, manage and integrate strategic plans for overall health care improvement, which includes Quality Indicators, Compliance reporting, Patient Satisfaction survey, and Performance Improvement processes.
Serve as the primary quality control resource for problem identification, resolution, loss reporting and continuous improvement.
Support concurrent engineering efforts by participating in design development projects representing quality assurance and the customer.
Establish and implement metrics (process capability, control charts, measurement quality) for monitoring system effectiveness and to enable managers to make sound product quality decisions.
Perform root-cause analysis and other problem solving activities to identify effective corrective actions and process improvements.
Educate and train employees as to their impact in the quality management system when needed.
Establish collection and analysis systems of statistical data to predict trends that will affect improvement of product quality.
Implement infection control measures, including isolation precautions and sterilization techniques in accordance with current rules, regulations, and guidelines that govern such requirements in nursing care facilities
Conduct surveillance of infection rates and report findings to the infection control committee.
Educate staff on infection prevention protocols, including hand hygiene, personal protective equipment (PPE) use, and safe handling of biohazard materials.
Develop and implement infection prevention policies and procedures in collaboration with the DON.
Tasks involve light contact with moist body substances, non-intact skin or mucous membranes. Department procedures define and require use of minimum protective measures to perform the task.
Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control or standard/ universal precautions.
Includes other duties assigned by Director of Nursing or CAO.
Serve as a resource for infection prevention best practices to nursing and clinical staff.
Participate in interdisciplinary rounds and provide input on infection control.
Educate/In-service of nursing staff, new hires, and yearly to ensure competency nursing personnel
Assist all departments in evaluating and classifying routine and job-related functions to ensure that tasks involving exposure to blood/body fluids are properly identifies.
Working knowledge of OSHA Blood borne Pathogen Standards, OSHA Tuberculosis, Title 22, State and Federal laws related to communicable disease, and DNV Standards.
Maintain accurate documentation of infection prevention activities, and patient progress in electronic medical records (EMR).
Prepare infection surveillance reports and data analysis for infection control meetings per facility protocol and accrediting body standards.
Prepare infection surveillance reports and data analysis for monthly reporting to National Healthcare Safety Network (NHSN)
Prepare infection surveillance reports and data analysis of ‘reportable’ cases for County Public Health.
Maintain culture and sensitivity logs for Hospital Acquire Infection tracking for Emergency Department, Acute Care, and Medical Specialty Centers.
Prepare infection surveillance reports and data analysis for Internal auditing and Quality improvement projects.