Job DescriptionSchedule: Monday - Friday, 7:00am to 3:00pm
A Brief OverviewResponsible for an infection prevention and quality program throughout the Surgical Services Division. Promotes excellence in quality and patient safety by preventing healthcare associated infections (HAIs) through surveillance, investigations and taking action to reduce the transmission disease. Maintains an effective Surgical infection prevention plan and conducts an annual risk assessment to determine infection prevention priorities utilizing the Association for Professionals in Infection Control and Epidemiology (APIC) competency model as a guideline. Responsible for coordination, implementation, and completion of projects in Surgical Services and Sterile Processing with specific deliverables. Promotes excellence in quality, patient safety, and service excellence by facilitating improvement across Children's Surgical divisions and provides improvement methodology education. Coordinates accreditation and regulatory continuous preparedness. Serves as a Liaison between Surgical Services and Infection Prevention.
Essential Functions- Accreditation & Regulatory Compliance:
• Assures the Surgical Services and Sterile Processing department's regulatory continued readiness through facilitation of multidisciplinary teams and work groups.
- Serves as consultant to department leadership and staff on standards interpretation and policy development to ensure regulatory compliance.
- Coordinates, leads, and conducts unit tracers to ensure standards compliance.
- Collaborates with Quality IP Surveillance and Reporting for all Surgical Site Infections reported through Infection Prevention Committee and Quality and Patient safety as well as the Surgical Services Division
• Perform periodic assessments of departments' adherence to regulatory standards using an electronic tracking management system.
• Coordinates external consultative assessment of regulatory compliance when requested by department leadership.
• Maintain compliance and regulatory department scorecards, collecting data from available sources.
• As required by Magnet and The Joint Commission, maintain and track patient satisfaction survey results and report as required
• Organize and execute safety, tornado, disaster, and fire drills as required. Document drills and results.
• Coordinate policy reviews with department leadership to ensure current policy compliance - Prevention and action to control the transmission of infectious agents:
Develop and review infection prevention control policies, procedures, and new guidelines based on current literature, regulatory agencies, and data generated through surveillance
Quality Improvement
- Works collaboratively with patient care services, ancillary departments, the medical staff, and multidisciplinary groups to identify opportunities for improvement for Surgical Services
- Utilizes evidence-based methodologies to improve systems and processes. Assures accountability assigned for sustainment of performance improvement activities.
- Responsible to collect, oversee, analyze and display data using tools and techniques that are appropriate for the intended audience.
- Facilitates all levels of cause analysis, develops standard documentation templates and event specific documents, and works with responsible staff to assure completion of selected actions
- Serves as liaison and Surgical Services resource to Nursing shared governance councils and hospital Interdisciplinary Committees.
- Analyzes and aggregates variance information, identifies trends, and reports findings to department and organization leaders as appropriate.
- Serves on Children's Organizational committees and workgroups as requested representing Surgical Service•
- Provide recommendations on products and procedures for cleaning, disinfection, and sterilization to minimize the transmission of infectious diseases
• Collaborate with public health agencies in planning community responses to biologic agents
• Identify and implement infection prevention and control strategies according to specific topics: hand hygiene; cleaning, disinfection, and sterilization; specific direct and indirect care settings; therapeutic and diagnostic procedures and devices; product/equipment recall procedures; use of isolation/barrier precautions when indicated; patient placement, transfer, discharge; environmental hazards; use of patient care products and medical equipment; construction and renovation within the department.
• Conduct annual risk assessments and develop and maintain an effective infection prevention plan in accordance with regulatory guidelines for Surgical and Sterile Processing
• Collaborate with antimicrobial stewardship program for Preoperative Antibiotic Prophylaxis, Allergies, and Specimen collection
• Examine data and analyze situations to identify potential infection prevention risks and seek resolution
- Project management and performance improvement:
- Works collaboratively with project stakeholders to develop a comprehensive project plan. Project plans will include: Scope, Schedule, Cost, Anticipated Outcomes, Organization and Communications, Staffing, Risk and Issue Management, and Change Management.
- Perform project planning. Create, build, and update project schedules, project charters, project plans, status reports, and work breakdown structures.
- Foresee potential barriers in projects and communicate accordingly.
- Facilitate and lead project or serves as a Champion to project leaders
- Coordinates Implementation and manage project changes and interventions to achieve desired project outcomes.
- Collects, analyzes, and displays data demonstrating project performance, using appropriate tools and techniques to project evaluations and assessment of results.
- Influence others and move toward a common vision or goal.
• Facilitate workgroups, collect and analyze infection data for SSIs reporting to Leaderships and SPIPS
• Works collaboratively with patient care services, ancillary departments, the medical staff, and multidisciplinary groups to identify opportunities for improvement in infection prevention and patient safety
• Serves as subject matter expert to organizational groups to reduce SSI.
• Serves on the Infection Control Committee
- Education:
- Serve as a resource and educator for employees, medical staff, residents, students, volunteers, patients and the community by developing and providing orientation and ongoing infection prevention and quality initiatives.
- Shares their knowledge and skills through mentoring, research, publication, collaboration, leadership, and educating novice Infection Preventionists
- Regular attendance at work is an essential function of the job.
- Perform physical requirements as described in the Physical Requirements section
Education Qualifications- Bachelor's Degree in Nursing form an accredited college or university or equivalent health science Required or
- Master's Degree Preferred
Experience Qualifications- 3 years experience in nursing required or related surgical field (preferably in the operating room) Required
Skills and Abilities- Strong clinical knowledge and background
- Advanced knowledge base in current infection prevention practices
- Ability to work independently, organize work and set priorities
- Ability to apply appropriate criteria for identifying hospital acquired infections
- Proficient in capturing and analyzing data and preparing reports
- Advanced knowledge of performance improvement principles
- Proficient written and verbal communication skills.
- Proficient computer programing skills including word processing, graphics, spreadsheets and basic presentations
- Skills in negotiation, problem solving, educational, and quality improvement strategies
- Ability to handle unexpected situations calmly and in a professional manner
- Ability to be accountable to 24 hour call schedule
- Strong meeting facilitation skills
Licenses and Certifications- Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required and
- Basic Life Support from the American Heart Association Upon Hire Required and
- Certification in Infection Prevention and Control within 3 Years Required
