Has overall responsibility for IHA's Infection Prevention and Laboratory programs through the development, promotion, training and implementation of effective policies, protocols and procedures. Provides leadership and direction in:
Infection Prevention: Communicates standards throughout IHA; performs surveillance and updates training and resource materials as needed.
Lab Technical Consultant: Is responsible for technical and scientific oversight of in-office labs; Ensures CLIA compliance.
ESSENTIAL JOB FUNCTIONS:
- Has overall responsibility for IHA's Lab and Infection Prevention program through the development, promotion, training and implementation of effective safety and infection control policies and protocols.
- Has overall responsibility for IHA's Laboratory Services program. Ensures CLIA compliance and coordinates daily lab operations of all IHA physician laboratories. Continually strives to improve laboratory processes throughout IHA.
- Serves as a resource and works in collaboration with staff on IHA's accreditation required policies and procedures in regards to Lab and Infection Prevention.
- Utilizes Health Stream to ensure competency and standardization.
- Assumes additional duties as required.
Infection Prevention Responsibilities:
- 1. Implements infection prevention and control policies and procedures.
- 2. Educates and collaborates with organizational leadership, care providers, and other personnel on their roles and responsibilities for infection prevention and control.
- 3. Liaison with community partners external to IHA. Works with county agencies to address health hazards and health emergencies in the community.
- 4. Design, collect, analyze, manage and report findings from surveillance to appropriate personnel and departments in order to implement and revise system policies, procedures and work practices that are consistent with the overall goals of the Infection Prevention and Control Program.
- 5. Develop and conduct educational programs, as needed, on infection prevention.
- 6. Provides consultation and/or education for healthcare personnel on potential and identified infection control problems.
- 7. Distributes findings from surveillance and other activities, policies and procedures, guidelines, etc. and makes recommendations to appropriate individuals, committees, departments and offices.
- 8. Facilitates reports of communicable diseases and other health conditions to Michigan Disease Surveillance System (MDSS).
- 9. Supports adherence by personnel and facilities with regulatory, licensure and accreditation requirements involving infection control and prevention.
- 10. Updates and communicates disinfection and cleaning standards; serves as a resource for office safety liaison when questions arise and provides for training as needed.
- 1. Assists with meeting certification or accreditation requirements for CLIA. Interprets CLIA requirements and ensures compliance with the regulations set forth by these agencies. Attends biannual inspections as needed.
- 2. Communicates any changes at the offices to CLIA in a timely manner as needed, such as; changes in address, test menu additions or deletions, lab director and name changes.
- 3. Ensures that CLIA certificates are current.
- 4. Establishes an organizational lab policy and procedure manual – collaborates with offices/ divisions on specific requirements. Develops policies and procedures as needed and updates the manual to show these changes. Communicates changes to all involved offices.
- 5. Helps with training of laboratory staff and oversees annual assessment at each office.
- 6. Provides continuing education for staff in all offices.
- 7. Establish and periodically review a Quality Assurance (QA) program at each office 2-4 times per year. Reviews finding s with the site Laboratory Director and Laboratory Coordinator.
- 8. Establish a Quality Control (QC) program that will meet regulatory, as well as, manufacturer recommendations. Ensure that QC is being performed and recorded per policy. Helps to develop any necessary logs, etc.
- 9. Evaluates Proficiency Test programs and ensures enrollment if required. Investigates any failures and helps to troubleshoot and correct the cause of the failure.
- 10. Takes place in the evaluation and selection of new or replacement equipment. Helps to perform any validation and/or calibration procedures required. Secures appropriate training for the new test.
- 11. Takes part in the evaluation process of prospective tests for cost effectiveness and feasibility. This determination will be made in partnership with the appropriate personnel in the organization. Will help determine what may be performed at each office based on the CLIA certificate level that the office holds.
- 12. Establishes an instrument maintenance program, if necessary.
- 13. Helps to answer billing and coding questions for laboratory related issues by working with the IHA Insurance Coordinator and the IHA Insurance Specialist.
- 14. Leads the Laboratory Coordinator Group meetings on a quarterly basis.
- 1. Creates a positive, professional, service-oriented work environment by supporting the IHA CARES mission and core values statement.
- 2. Must be able to work effectively as a member of the Compliance team.
- 3. Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.
- 4. Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA's Employee Handbook.
- 5. Maintains general knowledge of IHA office services and in the use of all relevant office equipment, computer, and manual systems.
- 6. Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respect cultural differences.
- 7. Uses resources efficiently.
Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.
EDUCATION: BS degree in Medical Technology, Lab Science, Nursing or other Health Science or RN (RN incumbent or candidate must possess a valid, unrestricted Registered Nurse license for the State of MI).
CREDENTIALS/LICENSURE: Eligible for or hold Certification in Infection Control (CIC) preferred with ability to become certified with acquired experience.
MINIMUM EXPERIENCE: 2-3 years clinical experience in a healthcare related environment.