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Job Summary:

The Manager Infection Prevention organizes and manages integrated key activities related Infection Prevention for the organization. He/she works with leader to align department goals and tactics with hospital and system strategic goals under the direction of the Executive Director of Infection Prevention or Hospital Designee. This leader is facility-based and reports to the Executive Director of Infection Prevention at the System level or hospital designee as appropriate
The Manager is a subject matter expert and oversees infection surveillance and analysis activities to advance operational performance related to infections. This leader manages day to day operations for the infection prevention and control program. This includes ensuring appropriate data is collected and reported to national public reporting organization and for audit requirements. In addition, this individual is expected to maintain his/her current skillset and competency to actively practice in the daily function of an Infection Preventionist.
Responsibilities include compliance with The Joint Commission, CMS, OSHA, NHSN and State regulation, outbreak investigation, and education of physicians and team members of CDC and State Health Department guidelines and regulations.
The individual in this role will build and maintain a strong working relationship with Nursing and quality leadership. He/she will influence protocol and outcomes and through presentation of information to drive operations decisions and support consistency across the organization. The manager will be a Visible known leader within the facility, including leadership rounding,
The individual in this role is expected to support consistent adherence to System-level policies and protocol. He/she may be required to cross-cover to other facilities as a subject matter expert and to ensure continuous leadership presence. This manager will be available to mentor team members for personal and professional growth. This includes ensuring the knowledgebase of the team includes modern infection prevention concepts and processes

Core Responsibilities and Essential Functions:

Management of the Infection Prevention Department
- Accountable for all Human Resource functions including interviewing, hiring, orientation and performance reviews
- Accountable for payroll and personnel actions
- Addresses performance problems decisively and objectively
- Applies clear and consistent performance standards
- Provides team members with feedback and coaching
- Ensures team member opportunities for professional development and growth
- Participates in the Quality and Patient Safety leadership team Management of the Regulatory and Accrediting Requirements for an Infection Prevention and Control Program.
- Leads and ensures survey readiness for the Infection Prevention and Control Program in accordance with required CMS conditions of participation and Accreditation standards
- Ensures accurate and timely data for public reporting submission through the National Healthcare Safety Network (NHSN)
- Leads and authors the annual Infection Prevention and Control risk assessment
- Authors and implements the annual Hospital Infection Prevention and Surveillance Plans
- Analyzes and authors the annual evaluation of the Infection Prevention and Surveillance Plans
- Utilizes expertise to identify and respond to hospital and Hospital Outpatient Department risks and vulnerabilities.
- Develops and approves Infection Prevention and Control policies and procedures based on evidence.
- Collaborates with System Infection Prevention and Emergency Preparedness to develop mitigation, emergency procedures and education for emerging infectious diseases
- Participates in the development and implementation of system operational plans to mitigate harm to patients, visitors, medical providers and team members Management of the daily infection prevention operations
- Co-facilitates the Infection Prevention and Control committee (where applicable).
- Prepares and presents reports and statistical data for Nursing and Ancillary Support, Medical Staff committees, Quality Review Committee and Medical Executive Committees
- Validates data infection prevention related data for submission.
- Actively participates in system-wide infection prevention collaborative.
- Mentors the infection prevention team members on Healthcare Associated Infection (HAI) definitions and the annual definition modifications within the National Healthcare Surveillance Network.
- Analyzes HAIs for root causes and develops action plans with nursing units to mitigate future patient harm
- Participates in construction risk analysis by recommending construction and renovation barriers to ensure the proper level of infection prevention controls are identified and maintained
- Monitors and advises infection prevention practice
- Collaborate with leaders and escalates concerns regarding infection prevention
- Serves as the infection prevention subject matter expert on performance improvement teams

Required Minimum Education:

Bachelor's Degree Required and
Nursing or healthcare-related field Preferred and
Master's Degree Preferred

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse (Single State) or RN - Multi-state Compact

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 2 years experience in a healthcare leadership role (project, oversight, lead) Required and
Minimum 5 years experience in Infection Prevention in acute care setting or equivalent Required.

Required Minimum Skills:

Leadership, interpersonal, time management, change management.
Must possess a solid understanding of team dynamics.
Excellent verbal and written communication skills and relationship building.
Strong experience in The Joint Commission, CMS, OSHA, NHSN and State regulations.
Proven expertise in outbreak investigation.

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