PURPOSE STATEMENT:

Under the direction of the System Director of Infection Prevention, the Project Director of Infection Prevention is responsible for the development, implementation and review of the infection prevention and control program and guidance to the assigned facilities.  Leads the development and maintains the policies and procedures to support successful quality /patient safety outcomes and ongoing performance improvement in the delivery of healthcare to patients, identification of areas of opportunity, and coordination and execution of regulatory compliance programs as related to Federal, State and other agencies.  May provide orientation, education, and monitoring through data review and on-site consultation to assigned facilities. 

*PLEASE NOTE:  This position is 100% remote with 90% travel; traveling most weeks Mon-Thur, home Fri-Sat.*

ESSENTIAL FUNCTIONS:

Responsible for guidance, training, surveillance, and regulatory preparedness.  Provides leadership, oversight and direction to corporate team members supporting the infection prevention and control program across the service lines.  Performs duties with a positive, empathetic, and professional attitude. Recognizes that patient safety is a top priority.  

• Monitors and evaluates compliance with standards set by policy and industry through data review and site visit monitoring.
• Provides training for individual facilities as well as the facility leaders as a group
• Supports regulatory activity and provides expertise in collaboration with facility leaders and corporate support teams.
• Ensures facility compliance through monitoring, training and site visits.
• Monitors and responds to industry trends and emerging diseases.
• Ensure facility notifications designated medical, administrative staff and appropriate health department authorities all reportable communicable disease.
• Responsibilities may also include gathering, analyzing and presenting data, facts and trends on infection prevention to facility or corporate leadership.
• Assess and re-enforce infection prevention practices.
• Communicate therapeutically and professionally with patients, visitors, coworkers, and others in an effective manner.
• Regulatory preparedness – implement sustainable survey preparation and ongoing monitoring processes, including facility-level auditing and early-issue identification, to maximize achievement of zero- or standard-level survey outcomes.
• Develop corrective action plans for the resolution of areas of regulatory vulnerability or those which could compromise patient safety in collaboration with facility leadership.
• Ensure proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Assist in the development of Performance Improvement practices across the system and maintenance of same including analysis of data and prioritization of efforts to improve survey readiness and consistency of care delivery using expected best-practices.
• Serves as a technical advisor, educator and internal consultant to all hospital management, staff, and physicians on the use of performance improvement tools and techniques, analytical techniques, and statistical applications.
• Innovation – ensure thorough adoption of Acadia’s selected technology platforms to support patient safety, patient experience, and compliance with infection control standards.
• Collaborates with Operations, Facilities, Nursing and other key stakeholders to facilitate the successful opening of new facilities as assigned.
• This includes but is not limited to auditing, monitoring, training, etc..
• Provides onboarding and training to nursing leaders and facility infection prevention designees that includes:
• Documentation of the infection prevention and control program and its surveillance, prevention, and control activities
• Competency-based training and education of facility IP designee on infection prevention and control policies and procedures and their application
• The prevention and control of health care–associated infections and other infectious diseases, including auditing staff adherence to infection prevention and control policies and procedures
• Communication and collaboration with all components of the hospital involved in infection prevention and control activities, including but not limited to the antibiotic stewardship program, sterile processing department, and the water management program
• IP role in the facility’s quality assessment and performance improvement program, including data collection and analysis, to address infection prevention and control issues
• Competencies for the facility IP designee regarding protocols for high-consequence infectious diseases or special pathogens

STANDARD EXPECTATIONS:

• Complies with organizational policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality.
• Communicate clearly and effectively to person(s) receiving services and their family members, guests and other members of the health care team.
• Develops constructive and cooperative working relationships with others and maintains them over time.
• Encourages and builds mutual trust, respect and cooperation among team members.
• Maintains regular and predictable attendance.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• One or more years’ experience in infection control highly preferred.
• RN with infection control work experience Required.
• Graduation from an accredited school of nursing, medical technology, microbiology, or epidemiology. Bachelor's degree preferred.
• Working knowledge of agents which cause disease, reservoir, knowledge of spectrum of disease, disease carriers, modes of transportation, host factors that enhance susceptibility, colonization of infection and approach to control infection.
• Knowledge of the basic principles of epidemiology and the infectious disease process.
• Knowledge of relevant Joint Commission, CMS, CARF, DEA, and state/local standards and regulations.
• Advanced computer skills including Microsoft Office; especially Word, Excel, and PowerPoint. This includes the ability to demonstrate proficiency in the electronic medical record.
• Knowledge of office administration procedures with the ability to operate most standard office equipment.
• Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current professional license as required by state for nurses in the role.
• Certification by the Certification Board of Infection Control and Epidemiology preferred (may be required in some states).

ADDITIONAL REGULATORY REQUIREMENTS:

During periods of vacancy or when the IP designee does not have the education or expertise, may serve as infection preventionist or as the IP consultant of record for select facilities.   For Joint Commission facilities: The infection preventionist is appointed by the governing body to be responsible for the infection prevention and control program. The appointment is based on recommendations of medical staff leadership and nursing leadership.                                                                                                                                                                 

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances
(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

AHCORP

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