·         Maintain current Infection Control and Prevention plans, policies, procedures and programs.

·         Gather, disseminate and document information on patient care quality and infection prevention to facilitate compliance with requirements of accrediting and regulatory agencies.

·         Perform and document annual Infection Control Risk Assessment.

·         Coordinate and integrate all Infection Control and Prevention activities within the Hospital.

·         Advise and assist medical staff and allied health care personnel in the quality / infection prevention process.

·         Provide an ongoing assessment of the Infection Control and Prevention elements of the quality improvement program.

·         Coordinate the bi-monthly Infection Control Committee: Prepare the meeting agenda, minutes, and related meeting materials.  Maintain a close liaison with the Infection Control Committee Chairperson / Program Director for Infectious Disease.

·         Keep appropriate committees informed of changes in accrediting and regulatory standards related to Infection Control and Prevention; maintain a close liaison with other hospital department heads to assure coordination, standardization and continuity of Infection Control programs.

·         Provide in-services on Infection Control and Prevention topics, plans, policies, procedures and programs as needed.

·         Coordinate and/or perform studies related to Infection Control / Quality Improvement and prepare resulting reports.

·         Utilize the “Plan-Do-Check-Act” methodology of performance improvement.

·         Establish and maintain tracking systems for reporting infection control and surveillance data and ensuring that the programs result in quality improvement.

·         Keep current with state laws, federal laws and regulatory agency requirements for hospitals regarding infection control and quality management.

·         Ensure that policies, procedures, protocols, and processes reflect the most up-to-date evidence and guidelines from professional organizations such as:

o   Association for Professionals in Infection Control and Epidemiology (APIC);

o   Center for Disease Control and Prevention (CDC);

o   Healthcare Infection Control Practices Advisory Committee (HICPAC);

o   Society for Healthcare Epidemiology of America (SHEA);

o   Infectious Diseases Society of America (IDSA);

o   World Health Organization (WHO);

o    and others.

·         Assist Administrator/CEO in developing Medical Staff Bylaws, rules, and regulations to assure compliance with regulatory standards related to Infection Control and Prevention.

·         Assist Director of Quality Management in regulatory survey preparation and ongoing compliance.

·         Ensure compliance with measures for preventing exposure to blood borne pathogens.

·         Establish and maintain tracking systems for reporting data and detecting infectious outbreaks in all age groups of patients (18 years and over).

·         Participate in the Hazardous Material Program.  Hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.

·         Ensure that all employee occupational health requirements are met and maintained; including but not limited to annual PPD and fit testing.

·         Coordinate annual vaccination programs for employees and patients.

·         Coordinate hospital-wide hand hygiene program.

·         Act as administrator for National Healthcare Safety Network (NHSN) database and enter data as required.

·         Indentify, investigate, and report communicable diseases as required by law.

·         Educate staff and patient population about infection risk, prevention, and control.

·         Participate in orientation of newly hired staff to provide a foundation of education related to infection control and prevention.

·         Adhere to Hospital attendance policy, as outlined in the Employee Handbook.

·         Adhere to all components of the Hospital Compliance Plan in performing job duties and report any violations or suspected violations of the Plan to the Compliance Officer.

·         Demonstrate professional conduct and comply with hospital and departmental policies and procedures.

·         Participate in Performance Improvement activities as delegated by the Director of Quality Management.

·         Recognize patient abuse and follow policy for making appropriate referrals/interventions.

·         Revise, implement and monitor compliance with the seven safety plans within the EOC Management Program.

·         Comply with established Safety and Patient Safety Program practices.

·         Perform other duties as assigned or delegated by the Director of Quality Management.

·         Limit access to protected health information (PHI) to the information reasonably necessary to do the job and share such information only on a need to know basis for work purposes.

 (Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization.  Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.)