Infection Control/Performance Improvement Specialist

At Houston Methodist, the Infection Control/Performance Improvement Specialist is responsible for the development of performance improvement/patient safety initiatives and implementing and maintaining the multiple facets of the Infection Control Program. This individual maintains a routine surveillance program of patients, personnel, and the environmental problems that present a real or potential threat to the welfare of patients, visitors, or personnel throughout the institution. Promotes organization wide understanding of the overall quality and patient safety program and culture. Facilitates timely and effective resolutions of patient care issues. Serves as a resource to all levels of the organization relative to infection control and quality improvement activities, conducting or providing education as requested by staff or leadership. Coordinates teams as needed to drive change towards desired outcomes using appropriate performance improvement methodologies. Serves as a liaison between all departments and the Infection Control Committee.

PEOPLE ESSENTIAL FUNCTIONS

• Coordinates with others for the investigation, identification, and, as deemed appropriate, follow-up of contacts who are suspected or confirmed to have been exposed to relevant communicable diseases at Houston Methodist. (This activity shall include the notification of and follow through with the Employee Health Nurse when such contacts have involved hospital personnel.)

• Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data management/analysis functions to maximize outcomes.

SERVICE ESSENTIAL FUNCTIONS

• Uses national recognized definitions and best practice guidelines to maintain a practical surveillance program which incorporates the systematic and current review of healthcare associated infections (HAIs), significant communicable diseases, and environmental events with potential impact to patient, visitor and healthcare provider safety.

• Supports accreditation readiness initiatives. Participates in regulatory and accreditation surveys. Serves as system-wide resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences. Presents instructional material for orientations and continuing education relevant to infection prevention and control throughout the hospital.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Routinely conducts infection prevention process surveillance to identify potential process deficiencies which may impact patient safety and lead to HAIs. Recognizes and investigates clusters of infections, communicates the investigation results through appropriate channels, and facilitates the implementation of interventions to prevent future infections.

• Abstracts pertinent information and enters into department databases using standardized methods and processes. Routinely performs discrepancy management activities to maintain data integrity. Presents meaningful reports and analysis with measurement description, statistical information, and benchmarking information. Reports data to external agencies as needed.

• Contributes to the evaluation (at least annually) and documents the effectiveness of the Infection Control Program Plan. Facilitates (at least annually) the revision of the Infection Control Program Plan to include new goals and measures as deemed appropriate based on a concurrent risk assessment. Develops and revises policies and procedures to meet current practice standards. Data mines information and produces statistics and reports in a meaningful way for decision making in support of continued infection prevention.

• Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators are met. Provides basic analyses of hospital performance against patient safety, quality and outcomes measures. Utilizes results from performance improvement activities to identify and prioritize areas of focus for improvement. Evaluates and provides input on the effectiveness of performance improvement programs. Conducts record review for performance improvement, peer review, patient safety, risk management and other projects.

• Supports improvement efforts for potential or actual quality of care/risk issues including participation/facilitation of Root Cause Analysis (RCA), Failure Modes Effects Analysis (FMEA), or event review as needed. Supports leadership and staff with the development and implementation of process changes. Summarizes events and presents findings as needed. Facilitates systems' design to hardwire patient safety processes.

• Supports facility construction planning and collaborates with construction through Infection Control Risk Assessment activities. Escalates safety and infection control issues in a timely fashion.

FINANCE ESSENTIAL FUNCTIONS

• Collaborates with other departments to monitor use of resources related to infection prevention. Participates in cost reduction efforts by making recommendations to mitigate risk of infection. Proactively identifies quality and safety improvement opportunities through analysis of internal and external data, to include federal incentive programs as applicable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Responsible for facilitating and coordinating efforts aimed at implementing new standards as required by regulatory and accrediting agencies; including implementation of new or improved policies and procedures related to infection prevention.

• Designs, develops, and implements project plans related to strategic quality and safety initiatives. Manages reporting of these projects/measures to internal departments/committees and/or outside agencies, as needed. Provides oversight for these projects to ensure desirable outcomes are met.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. EDUCATION

• Bachelor degree in Nursing required

WORK EXPERIENCE

• Three years of experience in a hospital or outpatient clinical role

• One year of experience in a quality management and/or patient safety, risk management, infection control, decision support or similar information analysis role

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR
• RN-Temp - Registered Nurse - Temporary State Licensure within 60 days

LICENSES AND CERTIFICATIONS - PREFERRED

• CPHQ - Certified Professional in Healthcare Quality (NAHQ) OR
• CPPS - Certified Professional in Patient Safety (CBPPS) OR
• CIC - Certified in Infection Control (CBIC)

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of statistical analysis techniques and software

• Knowledge of performance improvement methodologies & principles

• Knowledge of the principles of patient safety

• Competent in Infection Control Practices including Isolation Precautions, hospital surveillance and construction projects

• Knowledge of accreditation and regulatory agencies requirements for performance improvement, patient safety, and infection control

• Ability to learn and apply use of databases for aggregation of data for analysis.

• Strong leadership qualities (task completion, motivation)

• Ability to independently analyze and solve problems

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes

Company Profile:

Houston Methodist The Woodlands Hospital opened in June 2017 as the eighth hospital in the Houston Methodist system. This 267-bed, 725,000-square-foot, full-service, acute-care hospital offers many of the same services as our flagship hospital in the Texas Medical Center. Also, on the beautiful hospital campus, located at the intersection of Interstate 45 and Texas State Highway 242, are two medical office buildings, which include a Breast Care Center; Cancer Center; infusion center; heart and vascular services; neurology; orthopedics and sports medicine; rehabilitation services; wellness services; an outpatient laboratory; and several other multispecialty physician practices. In January 2022, Houston Methodist The Woodlands opened Healing Tower — a $250 million expansion project that added 106 beds, focused on medical-surgical and women’s services, and provided nine operating rooms. The project also included the expansion of the endoscopy center, emergency department and diagnostic imaging department with an enhanced neurodiagnostic and interventional center.

Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law. VEVRAA Federal Contractor – priority referral Protected Veterans requested.

---