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Director of Infection Prevention

Company: St. Charles Health System
Location: Bend
Posted on: June 7, 2021

Job Description:



TITLE: Director of Infection Prevention

REPORTS TO POSITION: System Director of Risk Management and Patient Safety

DEPARTMENT: Risk Management and Patient Safety

DATE LAST REVIEWED: November 27, 2020

OUR VISION: Creating America's healthiest community, together

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.


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 departments.

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 instruments.

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 practices.

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 procedures.

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 Control Committee.

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 or organism.

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 process improvement.

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 accurate.

Supports the vision, mission and values of the organization in all respects.

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 requirements.

Preferred: N/A


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.


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 speech level.

Frequently (50%): Standing, lifting 1-10 pounds, grasping/squeezing.

Occasionally (25%): Bending, reaching overhead, carrying/pushing or pulling 1-10 pounds.

Rarely (10%): Walking, stooping/kneeling/crouching, climbing stairs.

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:


Caregiver Type:



Is Exempt Position?


Job Family:


Compensation (min.):

49.7/ Hour

Compensation (mid):

63.24/ Hour

Compensation (max):

76.79/ Hour

Scheduled Days of the Week:


Shift Start & End Time:

Keywords: St. Charles Health System, Bend , Director of Infection Prevention, Other , Bend, Oregon

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