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Job Summary:

TITLE:
Medical Director Infection Prevention
QUALIFICATIONS:
Active member of the medical staff. Full-time faculty appointment and appointed by the Board of
Directors following its receipt of a recommendation from the President, Chief Medical Officer, and
the Executive Committee. Board certification by a specialty board that is relevant to the services
provided by the clinical service. Georgia licensure.
EXPERIENCE:
Practicing Physician with a minimum of 5 years’ active practice experience. Knowledge of the organization
and operations of an integrated health care system including: information systems, and medical staff,
vendor and community relations. Available for on-going education in management/leadership.
RESPONSIBLE TO:
President, Vice President Medical Affairs/Chief Medical Officer, Department Chair
POSITION SUMMARY:
The Medical Director is a medical staff leader who establishes, together with the medical staff
and health system administration, the type and scope of services required to meet the needs of
patients and the health system; develops and implements policies and procedures that guide
and support the provision of services; recommends to the medical staff the criteria for clinical
competencies and privileges for each service member; conducts continuous surveillance of the
professional performance of all individuals with clinical privileges and scopes of practice on the
service; and assesses and improves the quality of care and services provided by the service.
Medical Directors shall work cooperatively with the other Officers of the Medical Staff and the President, Vice President Medical Affairs/Chief Medical Officer, Chief Nursing Officer,
Department Chair, or their assigned administrative counterparts.
DUTIES & RESPONSIBILITIES:
The Medical Director will carry out the duties and responsibilities in accordance with the
Wellstar MCG Health Medical Staff Bylaws. Responsibilities may include both clinical and
administrative duties.
a) Ensure compliance with Wellstar MCG Health’s Mission, values, medical staff
bylaws and all related policies, procedures, and protocols.
b) Provides support for medical staff governance which includes the direct
involvement in and oversight responsibility for compliance issues (i.e.,
EMTALA, HIPPA), physician services, medical staff applications,
credentialing, reappointments, and new physician orientation; assists in the
identification, development and implementation of the medical information
infrastructure that will support sound clinical decision making across the
organization
c) Assists in the identification, development, and implementation of the clinical
information infrastructure that will support sound clinical decision-making
d) Participates in the assessment of new technology for the department
e) Participates in the strategic planning process for the development of
proposed priorities for departmental programs and services
f) Participates in department’s operating and capital budgeting process
g) Assists Wellstar MCG Health in meeting accreditation and licensure
requirements by actively promoting and achieving practice standards that
meet Joint Commission standards, standards set forth by federal programs,
and state licensure requirements
h) Assists in the development and provision of continuing professional education
programs for the medical staff, support staff, graduate, and post-graduate
medical education and acts as a liaison with residency and clerkship directors
in matters concerning resident and medical student rotations ) Represents the hospital on assigned internal and external committees, task
forces, commissions, agencies and promotional or public relations efforts
regarding clinical/medical affairs; assists with the coordination of any
regulatory certifications, licensure, or other designations as appropriate to the
functional areas for which the position has responsibility
j) In collaboration with the medical staff leadership, assures that appropriate
quality improvement systems are in place to fulfill the operational and
strategic goals of Wellstar MCG Health
k) Actively promotes and participates in ongoing performance improvement
efforts of Wellstar MCG Health
l) Coordinates with CQE and Utilization Management to assure the proper
analysis of clinical and financial data for identifying trends and reporting
ongoing results
m) Ensures that clinical protocols, policies, and procedures are effective,
efficient, evidence-based when evidence is available, and consistent with
internal and external quality and patient safety standards
n) Supports Wellstar MCG Health’s strategies in the area of quality, patient
safety, patient satisfaction, and Patient-and-Family-Centered Care
o) Makes recommendations regarding space, equipment, and other resources
needed by the clinical service
p) Ensures that research being conducted within the clinical service is in
accordance with Augusta University and Wellstar MCG Health Policies
q) Fulfills other duties as delineated by the Medical Staff Bylaws
PERFORMANCE EXPECTATIONS GOALS AND MONITORING:
1) Direct surveillance activities for IP:
r) Direct, antimicrobial subcommittee in conjunction with ID Pharmacist
s) Develop, review, and revise antimicrobial utilization guidelines for the medical
staff
t) Annual surveillance plan and performance indicators for antimicrobial
resistance patterns. u) Review and analyze surveillance data on a regular basis.
v) Plan for and advance computerization of surveillance data to facilitate
analyses.
w) Identify outbreak situations and plan for their evaluation and containment.
x) Identify endemic infection problems and plan for their evaluation and
improvement.
y) Interface with professional staff and governmental agencies in related
matters.
z) Serve on appropriate institutional committees and appropriate external
committees and agencies.
aa) Assure compliance with appropriate accreditation and regulatory standards.
bb) Participate in Joint Commission preparation and site visits.
cc) Present Antimicrobial Subcommittee recommendations to the Executive
Committee
dd) Generate appropriate antimicrobial utilization criteria in order to decrease
total antimicrobial use. This will:
ee) Decrease development of resistant organisms
ff) Decrease adverse effects from antimicrobials
gg) Decrease MDR superinfections
hh) Decrease C. difficile infections
ii) Provide stewardship regarding appropriate diagnostic assays used in
Infection control and infectious diseases in conjunction with the microbiology
department and medical director.
jj) Develop transition team with the Antimicrobial Stewardship PA and
pharmacist regarding patients being discharged on outpatient antimicrobial
therapy (OPAT). This will:
kk) Improve antimicrobial stewardship
ll) Improve transition to outpatient setting
mm) Decrease length of stay
nn) Decrease use of central lines, PICC lines and midline catheters

oo) Decrease adverse effects from OPAT
pp) Decrease readmissions due to AEs or re-infections
2.) Provides consultation services:
a) Recommend control measures to the Infections Committee, professional staff
and Department Heads.
b) Provide Infection Prevention consultation Employee Health on pertinent
employee problems.
c) Facilitate the implementations of the pharmacy’s antibiotic stewardship
program and liaison with the Antibiotic Sub-Committee and the ID
Pharmacist.
d) Provide antimicrobial stewardship consultations to faculty and staff
e) TV/radio/newspaper interviews (-8 per year).
f) Provide infection control assistance to Georgia hospitals.
3.) Provides educational services:
1. Infection control lectures
2. Antimicrobial Utilization lectures Measure:
Quality Metric Triggers:
LOS Index
Mortality Index
30 Day Readmissions
PSI 3,5,6,9,10,11,12,13,15
Goals:
Improve antimicrobial stewardship and utilization throughout the system (inpatient and
outpatient)
Decrease incidence of MDR bacteria and infections
Decrease length of stay by improving transition to outpatient (OPAT)
Decrease use of central lines, PICC lines and midline catheters and thus line-associated
infections
Decrease adverse effects from OPAT therapy
Decrease readmissions due to AEs or re-infections during OPAT
Improve use of diagnostic assays to establish infections
Quality Goals:
Quality Review via Vizient Provider Insight

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