Responsible for the development and implementation of policies governing control of infection and communicable diseases and the development of a program for identifying, reporting, investigating, and controlling infections and communicable diseases. This position has the authority and responsibility to obtain consults as needed in order to make knowledgeable decisions. In addition, oversees the hospitals infection control, program to ensure compliance with regulatory agencies and the Infection Control Plan. Including but not limited to:
- Developing and implementing policies governing control of infections and communicable diseases
- Developing a system of identifying, reporting, investigating, and controlling infectious and communicable diseases
- Collaboration with staff and others in the design and implementation of the program
- Regularly assessing the program using an epidemiological approach that consists of surveillance, data collection, analysis and trend identification
- Coordination of the program with the larger community
- Education and training of staff on the program and related policy and procedures
- Coordination and communication with Medical Executive Committee, Leadership, staff, and the Patient Safety and Quality Improvement Committee, Staff, and others on the program, data, and priorities and goals
- Coordinating the processes for investigating Outbreaks and Exposures
- Collaborating with the Human Resource department and leadership for the immunization, screening, and post exposure for employees and others as indicated
- Collaborating with the Human Resource department and leadership in the development and maintenance of the processes for identifying employees with infectious diseases and coordinating any work restrictions, referrals, and/or care as indicated.
- Annual review and revision of the Infection Control Plan
- Coordinating the hand hygiene program and improvement activities
- Hand hygiene program
- Infection Control Committee coordination and records
- Serves as the resource person during epidemiological events, employee exposures, and employee health
Core Measures Abstraction:
Maintains a concurrent and ongoing review process for the review of medical records for the core measure and coordinates efforts for improvement including but not limited to:
- Providing care givers with education on inadequate documentation and facilitates resolution prior to chart being closed
- Coordinates with nursing and medical staff leadership on improvement opportunities
- Works with Quality to coordinate the chart review process to ensure 100% of the charts are abstracted and data entered to meet the deadlines of Joint Commission, CMS and other regulatory agencies and organizations.
- Participates in chart abstraction validation reviews and ensures improvements are incorporated
- Achieves validation scores >75%
- Maintains current knowledge in core measures and abstraction guidelines to ensure program compliance
- Provides performance data to nursing and medical staff
- Participates in the preparation and presentation of core measure reports
- Provides training and education as needed to other staff on abstraction standards and procedures.
- Provides assistants to the case managers, clinical leaders, and others as assigned:
- Assisting in social service referrals, case review, data entry, or special projects
- Provides orientation/training programs, in-service, education and other education programs and materials needs
- Serves as a resource for clinical and medical staff and assists in the development of orientation and education programs for clinical personnel.
Takes full responsibility for all functions within job description and prioritizes to meet deadlines on daily work and special projects.
Ensures patient, medical record, employee, and department confidentially is maintained at all times.
Follows hospital and department policies and procedures at all times.
Emergency duty may be required of the incumbent including, but not limited to, responses to threats or disasters, man-made or natural.