Responsibilities
I. JOB SUMMARY:
• Leads the systematic identification, review, validation, and reporting of healthcare associated infections (HAI) and surgical site infections (SSI) in accordance with CDC National Healthcare Safety Network definitions and reporting requirements.
• Serves as the subject matter expert for HAI and SSI surveillance methodology, data integrity, and regulatory reporting, and works closely with clinical teams, Quality, Epidemiology, and leadership to ensure accurate classification and timely submission of events.
• Implements, monitors, and continuously updates a comprehensive infection prevention and control surveillance program that addresses both patient care and employee health.
• Utilizes epidemiologic methods, surveillance systems, and evidence-based practices to reduce the risk of healthcare-associated infections and ensure compliance with regulatory requirements across The Queen's Health Systems.
II. TYPICAL PHYSICAL DEMANDS:
A. ESSENTIAL FUNCTIONS:
• Seeing. Hearing. Speaking. Finger dexterity.
B. MANUAL MATERIAL HANDLING:
• Infrequent: N/A
• Occasional: Lift floor to waist between 0-5 lbs. Lift waist to shoulder between 0-5 lbs. Lift waist to overhead between 0-5 lbs. Carry between 0-5 lbs. Push and Pull between 0-5 lbs.
• Frequent: N/A
• Constant: N/A
C. NON-MANUAL MATERIAL HANDLING:
• Infrequent: Crawl. Gripping.
• Occasional: Sit. Stoop/Bend. Kneel. Twist. Climb: Stairs/Ladder. Reach: shoulder level. Reach: above head.
• Frequent: Stand. Walk.
• Constant: N/A
III. TYPICAL WORKING CONDITIONS:
• Not substantially subjected to adverse environmental conditions.
IV. MINIMUM QUALIFICATIONS:
A. EDUCATION:
• Bachelor's degree in a health related field.
• Successful completion of the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) training.
• Master's degree in Public Health or Nursing preferred.
• Successful completion of APIC's EPI 101 or comparable course preferred.
B. CERTIFICATION AND LICENSURE:
• Current certification in Infection Control (CIC) through the Certification Board of Infection Control (CBIC). If not certified, certification must be obtained within one (1) year of entrance into the position.
• Hawaii State license as a Registered Nurse, Medical Technologist, or Clinical Laboratory Scientist preferred.
C. EXPERIENCE:
• Four (4) years of professional experience in infection prevention within an acute care setting.
• Three (3) years of direct experience conducting healthcare-associated infection (HAI) and surgical site infection (SSI) surveillance. Surveillance experience must include independent review, adjudication, and reporting of HAI and SSI cases to the National Healthcare Safety Network (NHSN). Experience in a comparable acute care facility is preferred.
• Experience to demonstrate the following:
o Knowledge of CDC NHSN surveillance definitions, protocols, and reporting requirements for HAIs and SSIs.
o Ability to interpret operative reports, device utilization data, and clinical documentation for surveillance purposes.
o Demonstrated experience performing detailed chart review and applying surveillance criteria in acute care settings.
o Proficiency with NHSN data entry, analysis, and validation processes.
o Knowledge of epidemiological principles, infectious diseases, microbiology, sterilization, sanitation and disinfection practices.
o Leadership and teaching experience, including adult education principles, and/or patient care practices.
o Knowledge and proficiency in Microsoft Office (Outlook, Word and Excel).
o Experience working in process improvement, epidemiology, or microbiology preferred.
o Experience with EPIC preferred.
o Experience with regulatory requirements for The Joint Commission, OSHA, and other federal and state agencies. State of Hawaii DOH experience preferred.
