HEALTHEAST JOB DESCRIPTION



HEALTHEAST JOB DESCRIPTION

LOCATION: HealthEast (Corporate)

DEPARTMENT: Infection Prevention and Control/Epidemiology

POSITION: System Director, Infection Prevention and Control/Epidemiology Services

JOB GRADE: 38 DATE: 12/08 APPROVED BY: Karen MacDonald

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To be Completed by Human Resources

JOB CLASS CODE: 1461 FLSA STATUS: Exempt APPROVED BY: Carita Hibben___

CONTRACT: _ NON-CONTRACT: _X_

QUALIFICATIONS:

EDUCATION: Master’s degree in health or health administration-related field.

Current Minnesota license (if Registered Nurse).

Current Certification in Infection Control (CIC).

EXPERIENCE: Minimum of 5 years experience in acute care setting with least 3 years in infection prevention and control and 2 years of management experience (including experience working with physicians and various levels of hospital/healthcare management).

SPECIAL KNOWLEDGE, SKILLS, AND ABILITIES:

1. Demonstrated leadership experience.

2. Excellent written and verbal communication skills.

3. Excellent analytical and problem-solving skills.

4. Strong organizational and project management skills.

5. Effective skills in review of scientific literature and evidence-based research.

6. Ability to take complex scientific concepts and digest into practical understandable terms.

7. Knowledge of quality/performance improvement methodologies.

8. Knowledge of infection prevention and control practices.

9. Knowledge of epidemiologic investigative methodologies.

10. Knowledge of regulatory requirements (OSHA, CMS, MN Department of Health), accreditation standards (Joint Commission) and evidence based practice guidelines (CDC).

11. Ability to initiate, interpret, and act upon oral and written communication from or with physicians, peers, patients, family/visitors, supervisors and other departments.

12. Ability to relate to medical, administrative, clinical and professional staff to facilitate quality/performance improvement and infection prevention and control activities.

13. Ability to establish effective interpersonal relationships and utilize team facilitation skills.

14. Knowledge of management information systems and software programs for data analysis and presentation.

15. Must commute between HealthEast system sites as needed.

REPORTS TO: Associate Administrator, Quality and Care Management

DIRECTION OF OTHERS: Provides direction for and management of all Infection Prevention and Control Specialists, Program Analysts, Data Systems Coordinator and Data Assistant for the Infection Prevention and Control Department across the HealthEast Care System.

PRIMARY FUNCTION: Responsible for establishing mission, vision, planning, direction, assessment and leadership for effective infection prevention and control programs system-wide for HealthEast hospitals, clinics, outpatient services, ambulatory surgery centers, home care, hospice, transportation and other system entities in the areas of surveillance, reporting, prevention and control of infections including related regulatory compliance, accreditation standard compliance and quality/performance improvement. Serves as the infection control officer as delegated by the Hospital Epidemiologist.

MAJOR RESPONSIBILITIES:

1. Provides strategic and operational direction for the framework of an integrated system-wide approach to Infection Prevention and Control that spans the continuum of care.

Standards:

A. Designs and implements a mission statement, a vision, a risk assessment and a strategic plan for HealthEast (HE) Infection Prevention and Control.

B. Develops goals, objectives and action plans in accordance with the HE and Infection Prevention and Control mission and strategic initiatives to decrease the impact of healthcare-associated infections and occupational exposures to infectious agents.

C. Prioritizes objectives to align with strategic initiatives and budgets; keeps entity programs focused on clinical priorities.

D. Evaluates progress and revises strategic plan as needed.

E. Manages infection prevention and control/epidemiology department daily operations, providing assistance to IC Specialists with clinical or customer-service issues.

F. Responsible for organization and coordination of the Infection Prevention and Control Committee (a medical staff standing committee) in collaboration with the committee chair, physician epidemiologist and other physician leadership.

G. Serves as HE system administrator with Premier for the infection prevention and control data mining/management system (Safety Surveillor) for all hospitals.

H. Serves as HE NHSN (National Healthcare Safety Network) Facility Administrator for all HealthEast hospitals for purposes of internal surveillance, public reporting and CMS compliance.

2. Directs and coordinates the infection prevention and control program HealthEast-wide through a variety of activities involving medical staff and system personnel to ensure protection of patients, families, visitors, employees and other healthcare personnel providing services in HealthEast facilities from acquiring or disseminating an infection.

Standards:

A. Provides leadership for development and implementation of a HealthEast-wide risk-based surveillance system that identifies healthcare associated infections and provides the direction for surveillance activities.

B. Provides leadership for the analysis and reporting of infection data, developing action plans and interventions, and assessing the success of the actions in follow-up.

C. Designs, with key stakeholders, data-driven, cost-effective interventions to reduce healthcare associated infections and occupational exposures, and facilitates the implementation of interventions system-wide.

D. Consults with HE Physician Epidemiologist regarding infection rates, exposures, outbreaks and other infection prevention and control issues.

E. Provides administrative direction to ensure that surveillance programs and interventions to reduce infections and occupational exposures are supported by scientific research, or are innovative but based on sound principles of epidemiology and knowledge of disease transmission, and demonstrate potential for improving clinical outcomes and decreasing costs where possible.

F. Evaluates annually the effectiveness of the infection prevention and control plan and programs and recommends changes as needed.

G. Provides direction for the staff in areas of questions regarding room placement and isolation techniques for management of infectious patients.

H. Collaborates with the Employee Occupational Health Service in following up on employee infections, exposures to infectious patients, and in developing and implementing policies related to infection prevention and management of healthcare personnel with infectious conditions.

I. Directs studies related to infection incidence and control measures as needed and determines need for personnel and environmental cultures in the context of epidemiologic investigations.

J. Integrates infection prevention and control measures into newly developed services across the continuum of care.

K. Directs review process of HealthEast-wide policies and procedures for infection prevention and control.

L. Initiates and conducts environmental rounds at HealthEast clinics at least annually to identify and give direction for opportunities to improve.

M. Serves as the administrative lead consultant and content expert resource for HE Organizational Communications/Marketing on infection prevention and control related topics.

N. Serves on the HE Patient Safety Committee as the system representative for infection prevention and control.

O. Serves as the system representative for infection prevention and control to the HE Quality Institute Council.

P. Serves as the HE system Chapter Expert for the Joint Commission Standards on Surveillance, Prevention and Control of Infections.

Q. Serves as the HE system Infection Control Officer for the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation for Infection Control.

3. Provides administrative direction and organization for all system-wide epidemic investigations related to healthcare associated or community-acquired infections and/or occupational exposures in order to assure necessary patient safety and risk management practices are addressed following current evidence-based approaches and regulatory requirements.

Standards:

A. Evaluates and determines need for and directs epidemic/outbreak investigations.

B. Consults on design of data collection and investigation tools.

C. Directs the development of action plans and coordination of control measures.

D. Allocates or requests resources for investigation.

E. Directs problem resolution and formulates follow-up including reporting and communications.

F. Monitors progress and outcomes and makes recommendations to resolve issue in a timely manner using evidence-based strategies where possible.

G. Collaborates with HE Physician Epidemiologist and Infection Prevention and Control Committee Chair.

4. Coordinates, develops and provides education and educational materials regarding disease transmission and practices for infection prevention and control for all HE entities.

Standards:

A. Participates in HE orientation for new employees.

B. Assists the site Infection Prevention and Control Specialists with site based orientation and education programs.

C. Oversees and serves as content expert for infection prevention and control on HE annual mandatory education.

D. Provides education to all patient/family age groups regarding infectious diseases and infection prevention and control concerns, when requested.

E. Works and consults with external agencies and facilities in the communities served to promote infection prevention and control.

F. Partners with all business units to provide additional “just in time” education as deemed necessary or as requested.

5. Provides leadership and consultation to medical staff and HE leadership system-wide.

Standards:

A. Maintains effective communication to keep senior leadership, medical staff, sponsors, and stakeholders informed of infection prevention and control plans, activities and progress in meeting goals and objectives.

B. Updates hospital, clinic and outpatient personnel and medical staff about infection prevention and control issues.

C. Serves as administrative expert consultant to leadership, medical staff, sponsors and stakeholders on matters related to infection prevention and control including surveillance, epidemiology, outcomes measurement, quality/performance improvement and employee health.

D. Acts as a resource and advocate for Infection Prevention and Control Specialists as they interact with clinical units on procedures, techniques and equipment related to infection prevention and control.

E. Acts as a resource to departments in developing infection prevention and control policies.

F. Provides expertise to entities within the HE continuum, such as Transportation, Home Care, Hospice, Outpatient Services, Parish Nurse Program etc., as requested.

G. Serves as liaison with the local and state public health agencies and the CDC, and seeks their expertise as needed.

H. Participates as a team member during surveys involving Joint Commission, OSHA, CMS and the MN Department of Health. Serves as administrative lead for all standards and regulatory requirements as it relates to infection prevention and control.

I. Directs and serves as administrative lead for risk management with infection prevention and control construction planning, design and risk assessment for HealthEast.

J. Acts as administrative spokesperson for HE Infection Prevention and Control/Epidemiology, Collaborates with the HE Physician Epidemiologist and Administration.

6. Coordinates and participates in reporting of infection control information to appropriate medical staff and department committees, administration and hospital or system committees.

Standards:

A. Directs reporting of healthcare associated infection incidence to the HE Infection Prevention and Control Committee on a systematic basis; analyzes data, investigates significant clusters and unusual organisms as discovered through surveillance activities; recommends control measures; assesses effectiveness of actions.

B. Acts as liaison between healthcare staff, patients and physicians with the HE physician Epidemiologist and/or Chair of the Infection Control Committee.

C. Provides or delegates representation as a member of the following committees:

Infection Prevention and Control, Value Analysis, Collaborative Practice, Clinical section/department meetings, Dialysis Subcommittee, Environment of Care/Safety, Quality Management, Patient Safety, Nurse Practice, Emergency Preparedness, Accreditation, and other committees as requested or deemed appropriate.

7. Provides leadership for linkage with state, local and national organizations as well as community groups on matters focused on infection prevention and control.

Standards:

A. Collaborates with HealthEast leaders to assure active participation in groups such as the Institute for Clinical Systems Improvement (ICSI), Volunteer Hospitals of America (VHA), Institute for HealthCare Improvement (IHI), MN Alliance for Patient Safety (MAPS), the Advisory Board Company and others as appropriate.

B. Serves on the MN Hospital Association (MHA) infection control advisory committee.

C. Serve on the advisory board of the MHA for public reporting of infections in Minnesota.

D. Serves as an active member of the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC).

8. Directs the performance improvement process and reporting for infection prevention and control on behalf of HE administration across the system.

Standards:

A. Develops and submits an annual plan for performance improvement.

B. Implements and meets goals of plan within established time frame.

C. Attends all management inservices on performance improvement and educates self through use of multi-media resources (journals, books, conferences, webcasts etc.).

D. Provides direction and education of staff in the performance improvement process and the use of epidemiologic methods for infection prevention and control.

E. Provides the opportunity for customer service training for all employees.

F. Participates in system quality management/performance improvement planning activities and attends meetings as requested or assigned.

G. Utilizes customer satisfaction and other internal or external surveys to develop sensitivity to customer expectations and support action plans to continue to improve department services.

H. Directs the sentinel event review and reporting process for infection control matters using the established quality management process and HE policy and procedures.

I. Prepares and provides/presents reports on infection prevention and control programs and improvement activities to the HE Board Quality of Care Committee, System Leadership Council, Quality Institute/Quality Management Committee, Infection Prevention and Control Committee and other site or system entities as required.

8. Coordinates medical and hospital research projects regarding infection prevention and control issues, outcomes and cost-benefit studies.

Standards:

A. Conducts independent investigations and experimentation related to infection prevention and control and the epidemiology of healthcare associated infections. Coordinates chart reviews, data collection, analysis and reporting.

B. Develops written abstracts, papers and presentations; submits to national/local meetings.

C. Assists in the evaluation of study outcomes and takes necessary actions to effect changes in infection prevention and control practices that result in improved knowledge and/or clinical outcomes and reduced costs.

9. Understands and is committed to the HE Mission by demonstrating behaviors consistent with the Mission Statement, Core Behaviors and Core Behaviors for Leaders.

Standards:

A. Recognizes the personal dignity of patients, visitors and staff as evidenced in responding to expectations, complaints and requests.

B. Recognizes and affirms the contribution of co-workers.

C. Communicates to appropriate personnel expressed concerns and needs of customers; works collaboratively with personnel in addressing internal and external customer issues

D. Leads by example and strives to enhance the exchange of information through effective communication.

10. Maintains confidentiality in all aspects of the job.

Standards:

A. Information from patient medical records is not revealed to others except in accordance with HE policy.

B. Refrains from discussing patient or staff identities, conditions or other circumstances in public, in areas potentially overheard by others or with persons who do not have a legitimate interest.

C. Secures written and electronic confidential documents in a manner that prevents unauthorized release.

D. Implements and communicates HIPAA requirements for patient privacy and information security.

11. Has responsibility for human resources management within areas of responsibility to achieve quality services and maintain positive employee relations.

Standards:

A. Implements and communicates human resources policies and procedures in a fair and consistent manner.

B. Leads and facilitates setting of department and individual goals and objectives.

C. Conducts timely performance evaluations consistent with HE policy.

D. Provides mentoring and feedback to staff for personal/professional development.

E. Conducts employee disciplinary procedures with appropriate documentation according to human resources policy and employee/labor relations laws and guidelines.

F. Selects qualified employees for employment according to human resources policy and employee/labor relations laws and guidelines.

G. Provides and documents ongoing training and development for employees as needed.

12. Promotes professional development of self and staff.

Standards:

A. Participates in a minimum of one hospital or corporate committee.

B. Encourages staff participation in appropriate inservice or educational opportunities.

C. Evaluates the effectiveness of educational activities.

D. Participates in a minimum of one professional organization.

E. Review the literature and provides articles for staff to review for updates in specialty areas.

F. Provides opportunities for staff to share with each other the content learned through educational programs.

G. Speaks at HealthEast, local, regional, state, or national conferences or contributes to internal communications or the literature in areas of infection prevention and control or program administration.

13. Provides direction for the fiscal management for department operations to ensure proper utilization of financial resources.

Standards:

A. Prepares annual capital and operating budgets according to established procedures within the established timeframe.

B. Establishes staffing requirements for infection prevention and control/epidemiology services.

C. Manages budget throughout the year to ensure necessary resources for efficient and effective operations

D. Utilizes financial resources within established budget and seeks approval for variances as needed; pursues cost savings within areas of responsibility and/or makes recommendations for other areas within HE.

E. Annually evaluates needs of Infection Prevention and Control program to assure necessary resources are available for an effective program.

F. Regularly reviews department financial responsibility reports to assure accuracy and maintain vigilance over use of financial resources.

G. States business case for infection prevention and control programs and reports on cost saving/cost avoidance due to prevention and control of infections, as possible.

H. Collaborates with HE Physician Epidemiologist in determining cost-benefit of infection prevention and control interventions and programs and the cost burden of healthcare associated infections and occupational exposures.

14. Maintains a working knowledge of and provides information to ensure compliance with rules, regulations and recommendations from Federal, State, and accrediting agencies as they relate to infection prevention and control.

Standards:

A. Ensures compliance with relevant Joint Commission standards by reviewing and understanding the intent for infection prevention and control activities.

B. Ensures compliance with OSHA regulations, in particular the Bloodborne Pathogen and Tuberculosis Exposure Control Plan requirements.

C. Ensures compliance with CMS Conditions of Participation as they relate to infection prevention and control.

D. Coordinates preparation for surveys and inspections in partnership with Infection Prevention and Control Specialists and designated HE resource personnel and processes.

E. Familiarizes self with HE Bylaws, rules and regulations, policies/procedures relative to Quality Management and Performance Improvement, Medical Staff and governing bodies and their involvement in the Performance Improvement and Infection Prevention and Control processes.

15. Provides administrative direction and leadership in emergency preparedness related to infection prevention and control, including emerging and reemerging diseases, bioterrorism, natural disasters and other issues.

Standards:

A. Serves as the system Infection Prevention and Control administrative representative to the HE Emergency Preparedness Advisory Committee.

B. Develops or coordinates development of infection prevention and control plans for bioterrorism, and other infection disease emergencies in consideration of HE disaster plans and the incident command system.

C. Serves as liaison with the MN Department of Health and local public health agencies on disaster planning and emergency response activities.

D. Directs and coordinates the dissemination of Health Alert Network (HAN) communications related to infection prevention and control.

E. Collaborates with the HE system director of emergency preparedness on planning, education and drills related to infectious disease threats.

F. Provides administrative direction on matters related to environmental contamination remediation (i.e. water damage) to support infection prevention and control for the safety of patients and healthcare personnel, in collaboration with Plant Operations, Housekeeping and other departments as appropriate to the event.

16. Understands and has read the HealthEast Compliance manual and all departmental compliance policies.

Standards:

A. Complies with the HealthEast and departmental compliance policies in performing all job duties

Rev. 5/22/09

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