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SalaryReporting to the Senior Vice President of Practice Management, the Infection Preventionist/Safety Officer leads and directs all infection prevention activities for the surgery centers and practices, including patient care and relations, accreditation compliance, risk management and safety, quality assurance/performance improvement, and infection control. Assists in the development of strategic plans and policies for improved quality throughout the centers and works with top management to ensure compliance with regulatory agencies. Creates and manages quality reporting for presentation to Management and the Governing Board. Performs auditing and monitoring activities as required to ensure compliance with laws and regulations.
Essential Duties and Responsibilities:
- Perform job in accordance with Company Mission, Vision and goals.
- Develops goals and objectives for infection control and safety.
- Prepares agenda and all pertinent quality improvement information to be presented to the Management and Quality Assurance Committee of all Surgery Centers affiliated with the Company.
- Participates in and responds to Joint Commission, State, and other regulatory surveys/inspections and requests.
- Serves as the designated infection control and safety subject matter expert.
- Develops, coordinates, and administers ASC-wide systems for risk identification, investigation and reduction.
- Develops, reviews, and revises policies and procedures related to Infection Control and Patient Safety in relation to ASC’s.
- Identifies, through the analysis process, a summary of issues and/or policies that have the potential to negatively impact clinical outcomes and/or the delivery of quality healthcare.
- Reports potential claims to carriers, review patient/family/physician complaints with the Compliance Department for liability risk and resolution.
- Provides support for all quality improvement/risk management activities within all ASC’s.
- Submits MHCC freestanding AS Facility Survey (COMAR 10.24.04)
- Coordinates improvement activities for successful accrediting, licensing, and certification surveys.
- Creates educational programs and competencies related to Joint Commission or other regulatory requirements and assists in educating and training staff.
- Actively leads Infection Control meetings.
- Maintains advanced training in infection control in the ambulatory surgical setting.
- Conducts annual infection prevention risk assessment.
- Conducts initial and annual TB/PPD Policy & Procedures assessments.
- Monitors infection control in each ASC, reviews data and records results to the Quality Dashboard for presentation to the MQA Committee.
- Monitors or oversees the internet for Infection Control related issues in an effort to remain current on Infection Control Standards and community, state, and federal requirements.
- Develops Infection Control policies applicable to the Surgery Center setting.
- Provides in-services and other educational opportunities for Surgery Center staff on Infection Control issues.
- Monitors and enforces staff compliance to established Infection Control policies.
- Delegate’s infection control surveillance and task related responsibilities to other staff members appropriately.
- Oversees infection control surveillance and task related responsibilities that have been delegated to others to ensure effective and desired results.
- Monitors flu vaccine program, reports results to NHSN (CDC), reviews Policy and Procedures annually
- Undergoes annual competencies specific to infection control surveillance and monitoring.
- Manages and reports on annual hazardous risk assessments.
- Assists the Compliance Department in managing/responding to incident reports and assists in completing annual trend analysis.
- Coordinates and actively participates in safety meetings.
- Develops safety policies and systems applicable to the Surgery Center setting.
- Conducts annual review of Emergency Preparedness Plans and monitors adequate completion of drills has occurred in each site (Mock Codes, Fire Drills and Emergency Preparedness Drills per JC requirements).
- Provides in-services and other educational opportunities for Surgery Center staff on safety issues.
- Monitors and enforces staff compliance to established safety policies.
- Oversees safety surveillance and task related responsibilities that have been delegated to others to ensure effective and desired results.
- Undergoes annual competencies specific to safety surveillance and monitoring.
- Checks work e-mail on a regular basis throughout the workday.
- Participate in and complete all required trainings and in-services.
- Performs other duties as assigned.
Minimum Qualifications:
- Bachelor’s Degree from an accredited college or university with five (5) years of related experience; OR an Associate’s Degree with seven (7) years of related; OR an equivalent combination of education and/or experience.
- Must have knowledge of Internet and Microsoft Office software (MS Word, MS Excel, MS PowerPoint, MS Outlook).
- Current/active license to practice as a Registered Nurse (RN) in the State of Maryland.
- Must have at least two (2) years’ experience working with Joint Commission, Accreditation for Ambulatory Health Care (AAHC), or Center for Medicare and Medicaid Services (CMS) standards and regulations.
- Must have excellent written and oral communication skills, including exceptional customer service.
- Must be able to establish and maintain effective working relationships with doctors, clinical staff, other co-workers and the public.
- Must be able to work individually as well as within a team.
- Must be able to follow both verbal and written instructions.
- Must be able to work a flexible schedule.
- Must be able to respond with patience and understanding during stressful conditions related to patient health and emergent situations.
- Must be able to multi-task and prioritize.
- Must demonstrate extreme attention to detail.
- Must possess strong organization skills.
- Must be able to problem solve and use reasoning.
- Must be able to meet predefined quality standards.
- Must maintain and project a professional attitude and appearance at all time.
- Must have a working knowledge of the healthcare field and medical specialty, as well as medical terminology.
- All staff are expected to have a strong desire to provide excellent customer service; to comply with the rules and regulations of those organizations to which we are accountable; to have high ethical and professional standards of conduct; and to have an attitude of wanting to continuously improve their own professional performance.
Preferred Qualifications:
- Two (2) years’ experience managing an infection control and safety program.
- One (1) year of prior experience working with an Electronic Medical Record (EMR).
- Two (2) years’ experience working in an Ambulatory Surgery Center (ASC).
Driving/Travel:
The employee must have reliable transportation. Travel for this position may be required up to 100%. While the primary workplace may be closest to the employee’s home, work assignments could be in any of the Company’s locations.
