ST. CHARLES HEALTH SYSTEM
TITLE: Director of Infection Prevention
REPORTS TO POSITION: System Director of Risk Management and
DEPARTMENT: Risk Management and Patient Safety
DATE LAST REVIEWED: November 27, 2020
OUR VISION: Creating America's healthiest community,
OUR MISSION: In the spirit of love and compassion, better
health, better care, better value
OUR VALUES: Accountability, Caring and Teamwork
DEPARTMENT SUMMARY: The Infection Prevention division of System
Risk Management and Patient Safety provides infection prevention
and control program services which are designed to provide a safe,
sanitary and comfortable environment and to help prevent the
development and transmission of communicable diseases and
infections in our multi-hospital facilities including Cancer
Center, Level 3 NICU, Level 2 Trauma Center, Sage View Psychiatric,
Hospice, Home Health and Clinic system services. IP services
include infection prevention risk assessment, plan development and
implementation, surveillance, reporting, investigating and
controlling infections and communicable diseases for all providers,
caregivers, patients, visitors, and individuals providing services
under contractual arrangements.
The Director of Infection Prevention (IP) is responsible for
directing Infection Prevention and Infection Control programs
across the St. Charles Health System including Cancer Center, Sleep
Center, Sage View, Hospice, Home Health and Clinic Services. The
Director drives the development of programs that ensure safe
environments for patients and caregivers, evaluates and reduces the
risk of transmission of infections including activities related to
surveillance, prevention and control of infections. Other
responsibilities include facilitating the development of infection
prevention related policies, procedures and educational programs to
comply with local, state, federal, Joint Commission and CDC
regulations and guidelines. The Director of Infection Prevention
performs a key leadership and consultant role in a pandemic
response. The Director of Infection Prevention supervises infection
prevention registered nurses.
ESSENTIAL FUNCTIONS AND DUTIES:
Accountable for development and implementation of a
comprehensive Infection Prevention and Control Plan with a strong,
patient-centered commitment to excellence in prevention and control
of healthcare associated infections, positive clinical outcomes,
cost efficiency, performance enhancement and high professional
standards in accordance with all regulatory requirements.
Accountable for reporting compliance with the standard
surveillance definitions of the Centers for Medicare and Medicaid
Services (CMS), state and local reporting agencies, the centers for
Disease Control and Prevention's (CDC) and the National Healthcare
Safety Network (NHSN).
Responsible for ensuring an effective communication and working
relationship with the local and state Public Health
Directs targeted nosocomial infection surveillance program as
well as laboratory report surveillance program designed to identify
epidemiologically significant pathogens.
Collaborates and provides consultation to Caregiver Health for
investigating and providing follow-up direction to Caregivers
exposed to a communicable disease or to provide the names of
exposed patients to physicians for notification and follow-up.
Provides guidance and training for contact tracing.
Provides consultation for, and directs the IP Nurse roles and
responsibilities for developing and supporting Caregiver education
for individual departments including general orientation and annual
review as needed including: hand hygiene, cleaning, disinfecting
and sterilization, special direct and indirect care settings,
therapeutic and diagnostic procedures and devices, use of
isolation/barrier precautions when indicated and patient placement,
transfer and discharge, environmental hazards, use of patient care
products and medical equipment including PPE and caregiver
immunization programs, and climate control storage for surgical
Participates in monthly multi-disciplinary environment of care
rounds to identify infection control safety violations including
environmental cleanliness, improper use of tape, hazards, torn
furniture, equipment storage, linen handling, construction project
requirements, adequate refrigeration monitoring of food and
medications, adequate temperature control of water for dishwashers
and patient laundry, supply storage standards, decontamination
procedures, proper use of PPE etc.
Provides consultation with Program leaders, departments and
committees in the hospitals and outpatient services on isolation
techniques and all other matters pertaining to infection control.
This includes the most recent isolation evidence based best
Partners with the Infection Prevention Medical Director to
evaluate evidence-based caregiver and provider infection prevention
and control practices and promote improvement activities and
standards of care for optimal patient outcomes.
Works in collaboration with the Environment of Care Safety
Director with ongoing preparedness for pandemic response, including
review of PPE products, procurement standards, volume, storage,
supply expiration, communication and incident command
Establishes infection control environment of care rounds
compliance with TJC, CMS, DPH, CDC including, quality review
documentation of water, air quality and surface testing in special
areas such as Pharmacy and Dialysis..
Oversees the Antibiotic Stewardship program and monitor's
providers' usage of antibiotics for reporting to the Infection
Evaluates the need for, develops and implements written policies
and procedures for infection prevention and control, including
those for standard precautions and for transmission-based
precautions, including when these should be used, the duration of
use, and the type of precautions needed for a particular infection
Oversees the system Infection Control Committee meeting schedule
to ensure timely reporting and review of surveillance and
investigation activities of all hospital acquired infections,
SSI's, water, air quality and surface testing monitoring results,
antibiotic stewardship compliance, vaccination compliance,
communicable disease monitoring and control and complete annual
program review and infection control risk assessment. Prepares a
regular IC Committee report for submission to the Medical Director
Quality and Safety Committee.
Responsible and accountable for safety alert system reporting
system of hospital acquired infections and other infection related
safety events; analyzes and reports trends and identifies
appropriate interventions to reduce risk and liability to the
organization. Works in collaboration with the Risk Management and
Patient Safety team to perform root cause analysis of selected
hospital acquired safety events.
Evaluates the infection prevention and control practices in
central sterile processing including the use of any instrument
flash sterilization and provides consultation to leadership for
Develops and monitors activities related to continuous quality
assessment and improvement; serving as a consultant, facilitator,
educator, and resource for the organization relating to
evidence-based practice infection prevention.
Responsible for budget development, regular monitoring,
accountability and meeting all operational targets for all areas
within span of control
Hires, directs, coaches and monitors the performance of all
direct reports, to develop and maintain a high performance team
that meets organizational and department goals
Monitors and ensure all direct reports are current with
compliance and safety requirements. Implements and manages all
organizational safety directives and goals
Provides and oversees team's delivery of customer service in a
manner that promotes goodwill, is timely, efficient and
Supports the vision, mission and values of the organization in
Supports Value Improvement Practice (VIP- Lean) principles of
continuous improvement with energy and enthusiasm, functioning as a
champion of change.
Provides and maintains a safe environment for caregivers,
patients and guests.
Conducts all activities with the highest standards of
professionalism and confidentiality. Complies with all applicable
laws, regulations, policies and procedures, supporting the
organization's corporate integrity efforts by acting in an ethical
and appropriate manner, reporting known or suspected violation of
applicable rules, and cooperating fully with all organizational
investigations and proceedings.
May perform additional duties of similar complexity within the
organization, as required or assigned.
Required: Bachelor's degree from an accredited school of
nursing. Master's Degree in nursing, education, hospital
administration, public health, or epidemiology.
Preferred: Master's Degree in Nursing (MSN)
Required: Current Oregon RN license. CIC certification. Valid
Oregon driver's license and ability to meet SCHS driving
Required: 7 years Infection prevention/control management or
related experience. 2 years management experience.
Preferred: 5 years of years of supervising or managing
multi-facility infection control programs.
PERSONAL PROTECTIVE EQUIPMENT
Must be able to wear appropriate Personal Protective Equipment
(PPE) required to perform the job safely.
Continually (75% or more): Sitting, keyboard operation, use of
clear and audible speaking voice and the ability to hear normal
Frequently (50%): Standing, lifting 1-10 pounds,
Occasionally (25%): Bending, reaching overhead, carrying/pushing
or pulling 1-10 pounds.
Rarely (10%): Walking, stooping/kneeling/crouching, climbing
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing
or pulling 11-50 pounds, operation of a motor vehicle, ability to
hear whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise, dust,
vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP
Schedule Weekly Hours:
Is Exempt Position?
Scheduled Days of the Week:
Shift Start & End Time: