RN – Infection Control - Quality Improvement, Risk Management

Description

JOB SUMMARY:

Designs, implements, and directs the infection programs for the Nursing Home and manages infectious waste management system. Infection control responsibilities include (but not limited to) surveillance, analysis, reporting activities as well as setting standards and evaluating compliance for practices that are associated with the prevention and control of health care associated infections. Facilitates and coordinates the facility Performance Improvement (QI) Program to assure compliance with Calhoun Nursing Home and other healthcare regulatory agencies to enhance the quality of resident care. Compile, organize, and analyze incident reports and help formulate action plan to reduce risk and incidences.

EMPLOYEE HEALTH:

Planning, implementing, evaluating, and analyzing employee health services to include pre-employment and annual health assessments, immunizations, work-related exposures, illnesses and injuries.

INFECTIOUS WASTE MANAGEMENT:

Evaluation, analysis, and establishment of standards for the effective control of special medical waste to include compliance with current regulations that address wastes generated by health care facilities. In order to provide the above services, educations, consultation, and guidance are provided to hospital staff, medical staff, patients/residents, families, and visitors. The program manager complies with the mandates of required accrediting and regulatory agencies and communicates pertinent information to the members of senior management and the medical staff officers.

EDUCATION, CREDENTIALS & EXPERIENCE REQUIREMENTS:

• RN with current Georgia state licensure. BS degree desirable.
• Job experience in infection control/epidemiology guidelines and specific regulatory licensure mandates from state and federal agencies.
• Knowledge of pertinent regulatory, accrediting, and advisory body requirements including, but not limited to, local and state regulations, and recommendations of the CDC.
• Working knowledge and ability to demonstrate a comprehension of medical and nursing education and patient care management, microbiology, pathology, immunology, epidemiology, and medical statistics.
• Ability to interact effectively with all levels of health care personnel in these facilities and other health care facilities, public health services at the local, state, and national levels, and the CDC.
• Must be able to take a leadership role in cost-effective prevention of transmissible diseases
• Active BCLS certification.

GENERAL REQUIREMENTS:

• Performs all job responsibilities in alignment with the mission and vision of the organization.
• Performs other duties as required and completes all job functions as per departmental policies and procedures.
• Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs).
• Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
• Wears protective clothing and equipment as appropriate.

GENERAL SKILLS:

• Ability to communicate in English, both verbally and in writing.
• Additional languages preferred.
• Strong written and verbal skills.
• Basic Computer Skills

WORKING CONDITIONS:

• General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.
• May be exposed to high noise levels and bright lights.
• May be exposed to limited hazardous substances or body fluids, or infectious organisms.
• May be required to change from one task to another or different nature without loss of efficiency or composure.
• Periods of high stress and fluctuating workloads may occur.
• May be scheduled as needed including overtime.

PHYSICAL REQUIRMENTS & DEMANDS:

• Have near normal hearing: Hear alarms/telephone/normal speaking voice.
• Have near normal vision: Clarity of vision (both near and far), ability to distinguish colors.
• Have good manual dexterity.
• Have good eye-hand foot coordination.
• Ability to perform repetitive tasks/motion.
• Continuously within shift (67-100%): Standing, Walking.
• Frequently within shift (34-66%): Bending/Stooping, Pushing/Pulling, Lift/carry up to 20lbs, Lift/carry greater than 20 lbs. with assistance.
• Occasionally within shift (1-33%): Sitting, Climbing, Twist at waist, Lift/Carry greater than 50 lbs. with assistance, Reaching above shoulder.

MISSION STATEMENT:

QUALITY HEALTHCARE: In our continuing effort to enhance the quality of life for the communities we serve, the Hospital Authority of Miller County is committed to the delivery of superior, safe, cost-effective healthcare through the provisions of education prevention, diagnosis and treatment.

JOB SPECIFIC COMPETENCIES:

• Develop, integrate, manage, and control the functional components of the infection control program. Update and seek approval from administration and the infection control committee annually.
• Develop, integrate, manage, and control the functional components of the employee health program. Update and seek approval from administration and the infection control committee annually.
• Organize and maintain a manual that reflects infection control and the infection control committee by serving on committees that facilitate integration of the infection control standards.
• Evaluate the effectiveness of current routine and emergency infection control measures practiced in the nursing home.
• Develop, integrate, monitor, and evaluate standard practices relating to the control of special m decal waste in the facility and the follow up required to comply with the current state regulations relating to special medical wastes.
• Communicates directly and/or indirectly with medical and nursing education staff on issues relating to employee health.
• Communicates directly and/or indirectly with medical and nursing education staff on issues relating to educational needs of health care providers.
• Support and contribute to the quality improvement program by performing statistical analysis of nosocomial infections and trending other indicators that measure quality of care associated with infection control and employee health services.
• Performs surveillance activities and applies and epidemiological approach to problem solving.
• Provides formal and informal education programs to all personnel.
• Makes appropriate and timely recommendations that influence the standard of care and minimize risk of disease transmission.
• Analyzes and projects infection risks and potential results of those risks to and from the patients, residents, employee, environment, and the community.
• Prepares, evaluates, and reports all patient facility acquired infections, notifies state of notifiable communicable diseases by culture report surveillance, monitors staff infections, and manages all employee exposure incidents from BBP, TB, etc. Maintains all reports and store IC records in department.
• Reports all findings to IC Committee at least on quarterly basis and more frequently if indicated and to MedicalStaff when needed. Maintains all IC Committee meeting minutes and distributes them as indicated.
• Develops QI indicators for IC department and implements plans to improve quality of care for patients and residents along with providing safe environmental setting for health care workers, Provides IC QI Coordinator and Committee in established QI reporting manner.
• Establishes standards that meet the licensing and/or accrediting guidelines.
• Participated in activities associated with the public health department that would be beneficial to the hospital, nursing home, and general public such as annual health fair.
• Ensures that IC continuing education programs are provided to all staff (20 percent of time).
• Provides updated information to all staff as regulations, practices, and equipment as changes are made to keep hospital and nursing home in compliance with current standards.
• Participates in regularly scheduled programs such as new employee general orientation and annual updates.
• Prepares the agenda and formulates the minutes for the Performance Improvement Committee meetings
• Report data to QI monthly.
• Report data to NRC monthly.
• Track med errors by nurse and report to DON.
• Look for trends with falls, behaviors, etc.
• Educate staff about areas of concern.

PROFESSIONAL REQUIREMENTS:

• Follows Code of Conduct policy.
• Adheres to dress code; appearance is neat and clean.
• Completes annual educational requirements.
• Maintains regulatory requirements.
• Maintains patient confidentiality at all times.
• Reports to work on time and as scheduled; completes work within designated time.
• Wears identification when on duty; uses computerized time clock system correctly.
• Completes in-services and returns in a timely fashion.
• Attends annual review and/or skills fair and department in-services, as scheduled.
• Attempts to end conversations and other interactions in a positive manner; leaves others with a good impression of the Hospital Authority of Miller County and its employees.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission statement of the organization.

GUEST RELATIONS STANDARDS:

(All guest relation violations are subject to disciplinary action up to and including termination):

• Always treat others in a friendly, helpful manner.
• Refers co-workers to proper sources when unable to provide an answer.
• Interacts with others in a professional and friendly manner.
• Takes interest in others and always gives full cooperation to fellow workers.
• Always maintains an open line of communication with other departments.
• Thoroughly familiar with the hospital and the services it offers.

OTHER:

Responsibility to Report: It is the responsibility of every employee of HAMC to comply with federal, state and local laws and regulations, as well as, HAMC Policies and Procedures. Every employee is help accountable to participate in, comply with and report concerns to his or her supervisor or the Compliance Officer if illegal or unethical behavior is suspected.

As an employee of HAMC, you have been granted user access to applicable ePHI systems based on your position. This user or role-based access is intended to give you the minimum necessary access to perform your job function(s) only and should be used only as applicable.

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.