HRJD.136 Infection Preventionist



JOB DESCRIPTION

Infection Prevention and Employee Health Nurse

|Department: |Nursing Administration |

|Reports to: |Chief Nursing Officer |

| | |

Job Summary:

The Infection Prevention/ Employee Health Nurse carries out the infection control duties of surveillance, education, and consultation. Reporting to the Chief Nursing Officer, the Infection Prevention Nurse will possess advanced knowledge in the area of infection control practices. The Infection Prevention continuously surveys all department activities and environment to prevent, control, and educate patients and staff on infection prevention. This position, under the direction of the quality department committees is responsible for the management and operation of the Hospital’s infection prevention program and employee health compliance.

MAJOR TASK, DUTIES AND RESPONSIBILITIES:

1. Managing critical data and information, including surveillance of hospital-acquired infections (HAI) infections. Assist with collection of infection control data as directed which includes but is not limited to:

▪ Develop an infection prevention and control program that is demonstrated in written policy and procedures, training records, activity reports, surveillance reports, documented interventions and documented committee activity as appropriate

▪ Maintain the infection control manual of policy and procedures

▪ Provide consultation to all staff, departmental operations and service areas in infection prevention, surveillance and control

▪ Prepare the organization to meet the Federal and State [COP, OSHA and Title 22] standards and regulations for infection control

▪ Routinely perform surveillance activities as necessary to identify hospital-associated infections (HAIs), assess compliance with infection prevention and control procedures, and identify opportunities to improve the quality of care in all departmental operations and service areas

▪ Coordinate with the pharmaceutical service to monitor the appropriate use of antibiotics

▪ Select, implement and use infection control software that assists in the documentation and reporting of hospital-associated infections for patient care services and practitioners on staff

▪ Initiate appropriate epidemiological investigations in consultation with the Chief of Staff and Administration when evidence suggests an outbreak or exposure has occurred for the purpose of control, prevention, and process improvement

▪ Participate in the review of all products, upgrades or planned changes that have an infection control consideration

▪ Review all facility construction and remodeling for appropriate infection control methods during disruption. Consult with architectural planning for functional infection control considerations

▪ Provide formal and informal education relating to infection control throughout the organization. This would include the segment in new employee orientation to the organization’s standards of practice

▪ Assist the supervisors of Central Processing, Surgery, Laboratory Services and Environmental Services in the monitoring of the sterility and sanitation. This would include but not be limited to instruments, equipment, rooms and the implementation of procedures focused on the reducing the potential for the spread of infection within the facility and its services

▪ Monitor for reportable diseases for compliance with state and federal law and for the security of the quality of the patient environment

▪ Consult with patient care staff to collect specific infection data

▪ Complete data entry forms accurately

▪ Review department records on temperature & humidity for compliance

▪ Review patient care records & review all infections

▪ Formulate prevention plans and assist clinical departments with implementation plans

▪ Evaluate and monitor adherence to best practices & any performance improvement audits related to infection prevention

▪ Conduct environmental rounds monthly in all inpatient and outpatient care areas

▪ Act as an infection prevention resource for all staff

2. Prepares and presents reports and data analysis as directed by the Director of Quality. Data collected for reports (i.e. focus studies, communicable disease reports, post-exposure reports) is accurately aggregated and data analyzed, if appropriate:

o Standard:

▪ Accurate aggregated data for reports and studies prepared prior to the scheduled reporting month

▪ Data analyzed as directed by the Director of Quality

▪ Information pertinent to quality assurance and/or risk management is reported to the Director of Quality

3. Designated as infection control officer to develop and implement policies governing control of infections and communicable diseases.

a. Standard:

Infection Control Officer IC was qualified through education, training, experience, or certification coordinate the hospitals infection control program

4. Setting and recommending policies and procedures to insure rigorous infection control standards that meet Centers for Medicaid / Medicare Services (CMS), Centers for Disease Control and Prevention (CDC), Occupational Safety & Health Administration (OSHA) and other nationally organized agency recommendations and requirements. Written infection prevention and control policies and procedures must be established, implemented, maintained and updated periodically. Policies and procedures should be monitored periodically for performance:

a. Standard:

i. Writes and/or reviews policies and procedures as directed by the Director of Quality

ii. Participates in implementing new and existing policies and procedures

iii. Monitors infection control policy and procedures annually and reports results to the Director of Quality

5. Intervening directly to prevent transmission of infectious diseases. Able to identify and assist when needed in patient placement and transfer/discharge situations involving patients with communicable diseases/conditions. Possess the capacity to identify communicable diseases/conditions, occurrences of outbreaks and/or clusters of infectious diseases. In the event of an outbreak or cluster of infection, participates in investigation and implementation of appropriate control measures:

a. Standard:

i. No valid complaints received of patient placement or transfer situations involving patients with communicable diseases/conditions related to a decision made by the Infection Preventionist

ii. Identifies the occurrence of outbreaks or clusters of infectious diseases, when they occur

iii. Assists in the investigation and implementation of appropriate control measures for contagious diseases/conditions and in an outbreak or cluster of infection situation as directed by the Infection Control Committee Chair

6. Interacts with physicians, nurses, department managers and other professional and non professional staff members to resolve infection control problems and identify new opportunities to improve service by educating and training healthcare workers and providers. Able to provide ongoing educational orientation and programs in infection prevention and control to healthcare workers appropriate to the education level of learners. Able to evaluate education programs for effectiveness. Records attendance per Hospital policy:

a. Standard:

i. Provides infection prevention and control education for hospital orientation and classes/programs on infection prevention and control as directed by the Director of Quality

ii. Two classes per year will be developed, instructed and evaluated by the Infection Prevention nurse.

7. Plan, coordinate, and collaborate with Human Resources in the maintenance of employee records, vaccination requirements, and prevention practices.

a. Maintain current lists of employee health compliance records

b. Communicate with department leaders to maintain compliance

c. Establish employee records upon hire of new employees

d. Comply with state law in reporting certain communicable diseases and other reportable conditions diagnosed at Stanislaus Surgical Hospital

e. Provide guidance in the prevention and management of influenza concerning all Stanislaus Surgical Hospital’s employees.

f. Identify safe work practices to minimize the incidence of occupationally acquired diseases that are transmissible through aerosols in the healthcare setting.

g. Perform tests and oversee respirator fit testing program for airborne diseases

h. Assist with injury reports, investigation, and prevention.

8. Participates in Product Evaluation. Product review is conducted on new and, when appropriate, existing products to evaluate whether the product may contribute to a decrease in infection risk, or not increase the infection risk for patients and/or others. Invasive products and those used in sterilization; disinfection and cleaning as well as hand hygiene products have the highest priority:

a. Standard:

i. Products are reviewed and input is given in a timely manner for the Supply Standardization Committee

ii. No valid complaints are received regarding timely review

9. Participates in facility design, construction and renovation/remodels. The Infection Preventionist will work collaboratively with the Director of Plant Operations, project manager and/or other departments for risk assessment, planning and monitoring. Hospital Policies and Procedures for the assessment and management of construction, renovation, and maintenance activity will be used (as they relate to infection control and prevention) to reduce the risk of infection during and after construction, renovation or maintenance activities:

a. Standard:

i. Participates in infection risk assessment, planning and monitoring related to construction, renovation and maintenance as requested by the Director of Quality

ii. Documents participation in team meetings

iii. Documents findings during monitoring of projects and takes appropriate action if breeches of infection control permit are identified

10. Compliance with regulations, guidelines, and accreditation requirements. Collaboratively works with the local Department of Public Health and Employee Health Department on exposures to communicable diseases/conditions. Collaborates and provides liaison to appropriate local and state health departments for reporting of communicable diseases and conditions and to assist with the control of infectious diseases. Current regulations, guidelines and accreditation requirements are considered when developing policies and procedures, planning education programs, doing infection risk interventions and in surveillance activities. Participates in performance improvement activities as directed by the Director of Quality:

a. Standard:

i. No valid complaints received regarding exposure to communicable diseases or conditions follow up from Employee Health and Stanislaus County Public Health Department

ii. No valid complaints from Public Health Department regarding lack of information, accuracy of information submitted, or adherence to timeliness for reporting as set forth by Stanislaus County Health Department

iii. Policies and procedures, education programs, risk interventions and surveillance are consistent with current regulations, guidelines and accreditation requirements

11. Completes special projects, additional tasks as assigned. Includes participation on Performance Improvement teams upon request by the Director of Quality

a. Standard:

i. Performance to be evaluated in terms of:

1. Accuracy

2. Completion

3. Adherence to instructions

4. Cooperation

The above statement reflects the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

Minimum Qualifications:

Education:

• Graduation from an accredited school of nursing

Experience:

• Two years of experience in health care preferred

• Two years of experience in Infection Control or progressive experience in nursing, epidemiology, or public health may be substituted

Required Course(s)/Training

• Knowledge of data collection techniques

• Knowledge of microbiology terminology

• Basic mathematical, statistical and data analysis skills (rate calculation, trend analysis, etc.)

• Competent in the application and reading of skin tests

• Able to write legibly and effectively present ideas; document activities; read and interpret technical information

• Able to communicate (read, write, hear, understand) clearly and effectively in English to the degree required to perform the job

• Capable of basic computer skills-database management and word processing

Preferred Qualifications:

• Bachelors degree in Nursing or related field

• Attendance at a Center for Disease Control (CDC), State of California, or Association for Professionals in Infection Control and Epidemiology (APIC) sponsored Infection Control Training Course

Required Certification/Registration:

• Current RN licensure with the State of California

• Current Certification in Infection Control (CIC) by the Certification Board of Infection Control

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|Employee Signature | |Date |

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