Management & Supervision
Quality Improvement
Full Time
8 Hour Shift
Rancho Mirage, CA 92270
Job #
  • Job Objective: A brief overview of the position.
    • Manages the planning, development, implementation, evaluation/continuous improvement of an infection prevention and control program for the hospital and associated ambulatory care clinics.
  • Reports to
    • Director(s) Quality Improvement and Patient Safety Officer
  • Supervises
    • RN Infection Preventionists
  • Ages of Patients
    • Neonate/ Infant
    • Pediatric
    • Adolescent
    • Adult
    • Geriatric
  • Blood Borne Pathogens
    • High Potential
  • Qualifications
    • Education
      • Required: BSN
      • Preferred: Master's degree in nursing, public health, epidemiology, environmental health, microbiology or other public health related field
    • Licensure/Certification
      • Required: California RN License
      • Preferred: Certification in Infection Control
      • CIC® credential awarded by the Certification Board of Infection Control and Epidemiology, (CBIC)
    • Experience
      • Required: Minimum five (5) years of experience as an Infection Control Professional
      • Required: Minimum three (3) years of experience in an established infection prevention/control program in an acute care hospital including minimum (2) years of program management
      • Preferred: Demonstrated knowledge/experience in leading performance improvement initiatives
  • Essential Responsibilities
    • Program Management:
      • Manages the planning, development, implementation, evaluation/improvement of infection prevention and control services/programs that meet or exceed established standards/performance measures for quality, patient satisfaction, cost, employee quality of work life, physician and department satisfaction, clinical outcomes and regulatory compliance
      • Develop, evaluate and modify the annual surveillance plan based on the population(s) served, services provided and analysis of the surveillance data
      • Manages infection prevention and control services/programs in the hospital and ambulatory clinics. Ensures that services/programs are of uniform and consistent value, quality, performance and cost throughout all departments in the hospital and outpatient clinic buildings
      • Manages the development and implementation of evidence-based interventions designed to reduce/eliminate the risk for Healthcare Associated Infections (HAIs) and/or disease transmission
      • Acts as the Infection Prevention and Control liaison/consultant for the entire Medical Center and/or delegates appropriate duties
      • Manages surveillance activities and the monitoring, reporting and development of applicable intervention(s) for infection trends (e.g. National/Regional/ Divisional Indicators, Board Report, facility specific indicators, etc.) in the acute and ambulatory settings
      • Develops and reviews infection prevention and control policies and protocols
    • Design and Deliver Education:
      • Manages the preparation and response to emerging infectious disease threats and/or exposures
      • Serves as subject matter expert who assists medical center leadership team in internal or external disaster response/mitigation
      • Evaluates the effectiveness of educational programs and learner outcomes
    • Regulatory Requirements:
      • Manages the compliance with applicable regulatory requirements through interpretation of Regulatory Standards, investigation of disease outbreaks and exposures, surveillance and reporting communicable diseases to the CDPH as required
      • Manages the development and review of Infection Prevention and Control Standards of Care Policy and Procedure manuals
      • Serves as subject matter expert who assists medical center leadership team in internal or external disaster response/mitigation
      • Provides expert review and consultation for all facility construction/remodels as described in the Organization's Pre-Construction Risk Assessment (PCRA)
    • Performance Improvement:
      • Develops, implements and improves systems, methods, processes to evaluate/improve performance and quality outcomes/measures for infection prevention and control services/programs throughout the entire healthcare system
      • Utilize Performance Improvement (PI) methodology as a means of enacting change
      • Define the scope of the project and select appropriate PI tools to aid in efficiency, reliability, effectiveness and ensure sustainability of the initiative
      • Participate in PI committees, teams and initiatives as indicated
    • Occupational Health:
      • Assess the risk of occupational exposures to infectious diseases
      • Develop (or assist with) rates and trends of occupational exposures
      • Develop (or assist with) immunization and screening programs
    • Professional Accountability:
      • Pursue professional growth and development of required knowledge and skills
      • Maintain certification and licensure requirements
      • Establish at least one professional goal per year
      • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and reports suspected violations
      • Develops and maintains effective communication with administrative/management staff and physicians
      • Participate in an infection prevention and control professional organization/association (i.e. APIC)
    • Collaboration:
      • Consult and collaborate with local, state, and federal public health officials, and community health organizations.
      • Involve multidisciplinary teams to ensure changes are vetted and approved by all stakeholder groups
      • Develops and maintains excellent, collaborative relations with key stakeholders/departments including but not limited to: Employee Health, Nursing, Perioperative, Perinatal, Emergency Services, Urgent Care, and various physician specialties
      • In partnership with Infection Prevention staff and departmental managers develops, monitors and modifies Infection Prevention and Control Program department specific goals/objectives as appropriate
      • In partnership with the Sterile Processing Director/Manager provides expert leadership and knowledge to assure all sterilization and disinfection processes throughout the Hospital and Ambulatory Clinics are in compliance with all national and state standards
    • Leadership:
      • Bring enthusiasm, creativity and innovation to the IP program
      • Work collaboratively with others providing direction when necessary
      • Contribute to the development of healthcare providers through education and mentorship
      • Manage human resource processes; provides supervision and leadership to Infection Prevention staff; hires, fires, promotes, demotes, manages and evaluates staff performance and development
      • Prepare and deliver infection prevention presentations to external groups and organizations
    • Research and Implementation Science:
      • Together with the Infection Control Committee Chair, initiates and directs research projects and epidemiological investigations of significant clusters of infection or serious communicable disease concern
      • Critically evaluate research and evidence based practices and incorporate appropriate findings into routine practice
      • Integrate evidence-based practices into policies, guidelines, protocols and educational strategies
      • Identify barriers for implementation and develop strategies to minimize or remove barriers
    • Infection Prevention and Control Informatics:
      • Demonstrate expertise in infection prevention software and technology
      • Collaborate with Information Technology to create meaningful electronic reports to enhance infection prevention initiatives
    • Fiscal Responsibility:
      • Consider the financial/safety implications and clinical outcomes when making recommendations, evaluating technology and products and developing policies and procedures
      • Use a systematic approach to evaluate costs, benefits and efficacy
      • Manages and/or reduces costs
      • Assist with development and maintenance of departmental budgets
    • Performs other activities and responsibilities as directed