Employee Health/ Quality/ Infection Control/ Compliance Coordinator/ RN

Reports To: Chief Executive Officer

Job Overview:

This individual has oversight over all infection control and prevention related activities within the organization. This individual will also be responsible for all functions of the employee health program and for providing clinical employee health services at Philip Health Services. In addition, the individual has oversight over all quality and infection control related activities within the organization. Directs the efforts of all the performance improvement initiatives to ensure overall compliance with all regulatory standards including national, state, CMS, and other agencies. Position duties include performing specialized tasks, managing a team of staff members and establishing relationships with vendors and other professionals.

Supervisory Responsibilities:

None

Job Definition:

Full Time Non-Exempt

Duties/Responsibilities:

• Responsible for maintaining a systemwide Quality and Infection Control program; to include data collection, aggregating and analyzing data, maintaining policies and procedures, and reporting to administration, Medical Staff, and the Board.
• Development and implementation of Infection Prevention protocols facility wide.
• All documentation to demonstrate compliance.
• Competency based training and education of all staff including medical staff.
• Audits of compliance.
• Communication with antibiotic stewardship program.
• Will work closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Philip Health Services leadership.
• Serves as an internal consultant to administration, staff, and physicians in regulatory, process improvement, performance monitoring, and statistical analysis.
• Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
• Supports administration with employee health databases, maintains complete and accurate employee health records.
• Ensures compliance with the state and federal requirements, and Philip Health Services, Inc. policies and clinical responsibilities.
• Coordinates the development and implementation of all employee health initiatives and programs.
• Will develop, alongside Human Resources, policies and procedures for pre-employment and on-boarding processes for employees.
• Will be responsible for all pre-employment testing and vaccination processes, annual N95 fitting, return to work process, and the management of potential blood exposures, employee illnesses and disease outbreaks.
• Use epidemiological principles and statistical methods to design, implement and evaluate infection prevention and control strategies.
• Responsible for coordinating the infection control program which includes surveillance; analysis of data; developing reports, policies, and procedures.
• Conduct risk assessments and internal audits at least annually and as needed with consideration of served populations, regional vulnerabilities, relevant statistical data, and new and emerging infectious diseases.
• Notify the County and/or State Health Department of any reportable diseases, adhering to all internal county and state compliance and infectious diseases.
• Participate in infection prevention and control education of all employees during orientation and annually thereafter, including classes in infection prevention and control practices and employee health.
• Ensure the infection prevention and control procedures meet CMS, DOH (Department of Health), county, and CDC (Centers for Disease Control) (Centers for Disease Control) regulations, standards, or guidelines.
• Provides consultation and education to staff, physicians, and community leaders in respect to Infection Prevention & Control.
• Develop and implement continuously improved patient care procedures and control mechanisms relating to quality, compliance, and infectious diseases.
• Coordinate and manage Core Measures reporting and other functions.
• Collects and reports HCAHPS data for the facility.
• Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
• Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality i.e.: Core Measures, Hospital Acquired Conditions, etc.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, and efficiency using available information systems data. Where other data is necessary but not readily available, we will design and implement appropriate data collection. Uses data from appropriate external sources, including comparative databases.
• Manages project flow and alignment to assure milestones and key performance indicators are met within defined parameters. Documents the results of projects, and submits other documentation as requested.
• Evaluate and document the effectiveness of the quality management system of infection control activities.

Required Skills/Abilities:

• Detail oriented and capable of exploring innovative solutions to solve complex problems and address issues using a combination of delivered and custom developed tools.
• Ability to compile, code and categorize, or verify information/data.
• Strong organizational and interpersonal skills.
• Ability to determine appropriate course of action in more complex situations.
• Ability to work independently, exercise creativity, and maintain a positive attitude.
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
• Ability to maintain confidentiality of all medical, financial, and legal information.
• Ability to complete work assignments accurately and in a timely manner.
• Ability to communicate effectively, with excellent verbal and written communication skills.
• Ability to handle demanding situations involving patients, physicians, and others in a professional manner.
• Ability to use problem solving and conflict resolution skills to foster effective work relationships with team members.
• Attend required staff meetings and trainings.
• Skill in organizing and prioritizing workloads to meet deadlines.
• Ability to develop policies and procedures.

Education and Experience:

• A minimum of three years' experience in healthcare is required, Quality/IC leadership experience preferred.
• Current RN (Registered Nurse) nursing license
• Bachelor's degree (BSN) highly desirable but not required.
• Current Basic Life Support (BLS) certification
• Must be proficient and have a strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.)

Physical Requirements:

• Position will require travel
• Prolonged periods of walking, sitting, pushing, and pulling heavy objects
• Full range of body motion including handling and lifting
• Light to moderate work
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.