Director of Infection Prevention and Quality - Peoples Family of Corporations

Betty Jean Kerr People's Health Centers

Job Description

Job Title: DIRECTOR OF INFECTION PREVENTION AND QUALITY

Department: COMPLIANCE

Reports To: VICE PRESIDENT OF CLINILCAL SERVICES

FLSA Status: EXEMPT

Prepared By: HUMAN RESOURCES DEPARTMENT

Prepared Date: October 16, 2002; Revised: January 2007, October 2011, February 2018, Dec 2024

Summary:

Under the direction of the VP of Clinical Services, The Director of Infection Prevention and Quality is responsible for developing, implementing, monitoring and evaluating Betty Jean Kerr People’s Health Infection Prevention and Quality Programs. The Director provides organizational support, program assessment and ensures that the performance improvement and infection prevention processes are consistent with the mission and goals of the organization.

Essential Duties and Responsibilities:

Include the following…

Oversee and support Quality Management and Infection Prevention activities including but not limited to:

a. Internal and external chart audits

b. Infection Prevention Surveillance

c. Quality Assurance Surveillance

Participate in quality/performance improvement activities by assessing, monitoring, and measuring nosocomial infections and evaluating outcomes on a continuous basis.

Select indicators based on the projected use of the data. Plan and participate in the budget process.

Chair BJKPHC’s regularly scheduled Infection Prevention meetings and dissemination of recommendations agency wide.

Serve as a knowledgeable and available resource on infection control practices and policies to patients, families, staff and employees.

Participate in continuing educational activities at the department, state, and national levels to promote personal growth and maintain a current knowledge base commensurate with latest research and scholarly knowledge

Regulatory: Maintain compliance with national standards and regulating bodies such as AAAHC, CDC, OSHA, CMS, and FDA.

Responsible for providing reports and data summaries relevant to quality and infection prevention activities as requested by the VP o Clinical Services, CEO, CMO and other key employees.

Assist VP of Clinical Services, CMO and Directors/Managers in developing, submitting, and tracking plans of correction for improvement processes.

Responsible for facilitating various clinical quality committees and preparing Board Quality reports.

Other duties as assigned

Supervisory Responsibilities:

This job has no supervisory responsibilities.

Competency:

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Collects and researches data.

Design - Uses feedback to modify designs; Demonstrates attention to detail.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group and individual problem-solving situations; Uses reason even when dealing with emotional topics.

Project Management - Communicates changes and progress.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.

Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Participates in meetings.

Written Communication - Writes clearly and informatively; edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.

Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone's efforts to succeed; Embodies a team-based approach to patient care.

Visionary Leadership - Inspires respect and trust.

Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Accepts feedback from others; Gives appropriate recognition to others.

Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; educates others on the value of diversity; promotes a harassment-free environment; Builds a diverse workforce.

Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values; maintains confidentiality of information received.

Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Supports affirmative action and respects diversity.

Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

Motivation - Sets and achieves challenging goals; Measures self against standard of excellence.

Planning/Organizing - Uses time efficiently; sets goals and objectives.

Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors and proofs own work to ensure quality.

Quantity - Completes work in timely manner. Performs chart audits/reviews as expected.

Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.

Adaptability - Adapts to changes in the work environment; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative - Volunteers readily; Looks for and takes advantage of opportunities; Asks for and offers help when needed.

Innovation - Displays original thinking and creativity; Generates suggestions for improving work; Presents ideas and information in a manner that gets others' attention.

Qualifications, Education and/or Experience:

Requires RN

MSN with Infection Prevention experience preferred

Language Skills:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Mathematical Skills:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.

Reasoning Ability:

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Computer Skills:

To perform this job successfully, an individual should have knowledge of Database software and Word Processing software. Requires ability to compile reports; ability to use access, excel and other programs to present reports/graphs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit and talk or hear. The employee is frequently required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include ability to adjust focus.

To perform the job requirements, this position requires travel to all agency sites/locations and may require travel for required training.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Age Specific Requirements: Applicable

I acknowledge that I have read and fully understand the above job description and agree to abide by its content. I understand that failure to satisfactorily perform the assigned duties may result in disciplinary action and/or termination.

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Print Employee Last Name, First Signature of employee Date Signed Date Signed

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