Quality and Infection Prevention Manager

1 month ago

Boise, United States Trinity Health Full time
Employment Type:
Full timeShift:
Day Shift

Description:

GENERAL SUMMARY AND PURPOSE:

This position oversees the Quality Department at the assigned Saint Alphonsus Medical Center and the Infection Prevention Group for Saint Alphonsus Health System (SAHS). Responsible for planning, developing, implementing, and evaluating the overall SAHS Infection Prevention Plan and Program. Fosters and supports a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce error and improve patient outcomes cohesively across the system.

Work collaboratively with leadership, management, medical staff, and interdisciplinary staff across the entire organization to develop and implement measures to decrease infections amongst patients. Provides day-to-day oversight of the program including personnel management, deployment of resources, project management, evaluation of processes, analysis of data and continuous regulatory readiness.

Responsible for conducting/assisting with educational programs related to infection control and prevention, developing policies, and implementing performance improvement measures that ensure the medical centers meet the Infection Control requirements of CDC, OSHA, TJC and other federal and state regulatory agencies.

SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:

Minimum of a bachelor's degree in nursing or healthcare related field. Must possess comprehensive knowledge of evidence-based practices pertaining to infection reduction, data analysis and project management.

Two (2) years of supervisory experience required. Masters in healthcare related field strongly preferred.

ESSENTIAL FUNCTIONS:

Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. Organizes data from health records for special studies, projects, and programs. Keeps abreast of CMS regulations and changes. Provides education for facility employees, as it pertains to position responsibilities.

With local Quality Council input, annually reviews and recommends revisions as necessary to the SAHS Quality Assurance and Performance Improvement (QAPI) Plan. Takes inventory of existing PI activities at their assigned location, identifies needs, and maintains an ongoing inventory of activities through the Quality Council agenda/minutes. Assists in implementation of activities according to the QAPI Plan. Provides educational and technical assistance to departments or committees, as it pertains to position responsibilities. Keeps current with the medical staff bylaws, rules and regulations.

Coordinates facility-wide understanding and compliance with TJC standards. Initiates and develops, in collaboration with interdisciplinary SAHS leadership, the PI projects for infection prevention and reduction. Supports and encourages staff involvement in the PI program at their assigned location and, for infection prevention and reduction, throughout SAHS.

Acts as a resource to staff for PI project idea development. Motivates staff to take an active role in planning, developing, and assessing PI projects. Maintains an environment that breeds a culture of safety and reduced medical errors. Ensures completion of systematic surveillance of patients to identify hospital acquired infections through established criteria. Maintains or delegates the maintenance of databases related to surveillance and process/outcome metrics. Analyzes, displays, and communicates infection prevention data to leadership throughout SAHS.

Provides consultation on standards interpretation and implementation to hospital departments for the safety of health care services in relation to infection control. Participates as a member or consultant in organizational decision making, including the development of policies and procedures that affect the delivery of patient care. Demonstrates ability to work effectively with professional and supportive personnel throughout the medical centers to promote safety in relation to infection control.

Maintains current knowledge of evidence-based practice related to infection prevention and control. Identifies areas for performance improvement or study in the realm of infection prevention and control and leads/participates in performance improvement teams, as appropriate. Recommends changes in clinical practice based on current concepts and findings from regulatory and accrediting agencies, professional practice guidelines, and other research and /or studies for infection prevention. Knowledge of federal, state, and local laws, regulations and guidelines that affect infection control.

Knowledge of infection control requirements of CDC, OSHA, TJC, APIC recommendations and ability to interpret them in clinical settings. Must be highly motivated and self-directed. Must be capable of gathering data and making sound, mature decisions. Must command strong communication skills. Must have the ability to work under pressure with time constraints.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

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