Department:

Administration

Reports to (title):

Chief Executive Officer

Job Code:

Classification:

Exempt

Pay Range:

KPHC Pay Grade 12

Effective Date:

09/08/2022

Hours/week:

40

Revised Date:

09/08/2022

Type of Position:

Full-time

MISSION STATEMENT

The Kewa Pueblo Health Corporation (KPHC) is established for the purpose of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The VISION of KPHC is: “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE” and the MISSION of KPHC is: “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE”.

PERFORMANCE EXPECTATIONS

In performance of their respective tasks and duties, all employees of the Kewa Pueblo Health Corporation are expected to conform to the following:

• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to all professional and ethical behavior standards of the healthcare industry.
• Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
• Possess cultural awareness and sensitivity.
• Maintain a current insurable driver’s license.
• Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well as all applicable laws.

POSITION PURPOSE

Reporting to the Director of Quality, the Infection Control Nurse acts independently and in collaboration with other KPHC supervisors and functions to oversee the broad development, implementation, monitoring, collaboration, and reporting on KPHC’s infection prevention/control, employee health and safety programs and initiatives.

This position serves as a content expert on regulatory, government and accrediting agency requirements for effective infection control and employee health programs at KPHC, and works across departments to align organizational policies and practices with these standards. Serving as the Chair of the Infection Control Committee (ICC) Committee, the Infection Control Nurse also utilizes outside resources for complex questions regarding infection control and employee health as needed. In addition to leading and assisting with departmental efforts to collect, analyze, and act on systems data to establish goals and plans, the Infection Control Nurse also functions to summarize and present infection control and employee information for KPHC. To this end, the Infection Control Nurse trains staff annually and as needed on related tools and goals for KPHC, including the annual Infection Prevention and Control Program (IPCP) and employee health plans. The Infection Control Nurse is a dedicated member of KPHC’s Leadership Team (ELT) by virtue of position and function within the organization.

ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES

•          Develops, administers, and monitors the day-to-day implementation of organizational Infection Control and Employee Health programs, including surveillance and the development, maintenance, revision and coordinated approval of policies and procedures for these functions and the corresponding tools used.

•          Ensures that plans, goals, and policies are consistent with established KPHC-wide strategic goals and initiatives.

•          Serves as the Chairperson of KPHC’s Infection Control Committee (ICC).

•          Guides and provides direct input into the establishment of annual Infection Control risk assessments and Employee Health initiatives along with corresponding organizational goals for each function based on programmatic intent, operational and environmental analysis, and prior year performance/incidents.

•          Coordinates and engages annual, quarterly, and monthly surveillance and environment of care rounds/review(s) in accordance with accreditation standards (e.g. AAAHC, CMS, IHS, etc.) and reports findings to KPHC’s CEO, Leadership Team and Health Board as required.

•          Serves as a Survey Liaison with AAAHC and/or CMS for KPHC’s infection control and employee health programs.

•          Conducts physical surveys of KPHC facilities to gauge and maintain compliance with         regulatory requirements.

•          Provides training and education to KPHC employees and the Health Board on infection control and employee health topics as required, including initial orientation and annual modules for accreditation compliance.

•          Performs retrospective and concurrent review of specific focused studies (including disinfection and safe handling processes, environment of care and other studies) requested by medical staff, leadership and committees.

•          Identifies and examines patterns and variance for selected performance indicators relating to focused studies and assists with the implementation of quality improvement initiatives for KPHC staff as required.

•          Participates in data extraction and preparation for submission of required data analysis and conclusions to oversight and/or accrediting bodies, the CEO, Leadership, and Health Board for monthly, quarterly, and annual reporting.

•          Communicates with external agencies as needed for reportable issues (e.g. outbreaks and emergency response coordination) and relays critical issues to the CEO in a timely manner.

•          Serves as an active member of the Leadership Team in addressing performance deficiencies identified on Rolling Action Item Lists (RAILs), reports from inside (e.g. infection control and/or safety committees) and outside entities (including mock surveys), incident reports, and other points of information.

•          Maintains current knowledge of pertinent laws, standards, trends, tools, and techniques to maximize infection control and employee health effectiveness, including maintenance of applicable professional credentials through continuing education, as required.

•          Helping to manage any pandemic for Santo Domingo Pueblo as a member of the Unified Incident Command.

•          helping to write policies, and processes to help control and prevent any pandemic

•          Setting up Isolation and Quarantine areas for the community

•          Meeting with the Pueblo of Santo Domingo Governor, Tribal Council and New Mexico Department of Health to help with coordinating Pandemic efforts, education, testing and vaccinations.

•          Day to day duties:

       Helping to manage the COVID-19 pandemic for Santo Domingo Pueblo employees, as Employee Health, helping to write policies, and processes to help control and prevent COVID-19 within the clinic employees.

       Test the immunization status of the new employees (draw lab work)

       Assure that employee’s vaccination requirements are met (administer vaccine)

       Maintain an up to date employee files

       Maintain a Bloodborne Pathogen Exposure program

       Report positive lab results to the NM Department of Health, AASTEC, CDC, OSHA

       Helping to make recommendations on PPE to be utilized for the clinic’s employees

       Manage/report the vaccination records for the employees

•          Perform other duties as assigned.

MINIMUM MANDATORY QUALIFICATIONS

Education:

BACHELOR’S DEGREE IN NURSING, PUBLIC HEALTH NURSING, OCCUPATIONAL HEALTH AND SAFETY, OR A RELATED HEALTH PROFESSION.

Experience:

Three (3) years of healthcare experience in an ambulatory setting, with direct experience with infection control and employee health program administration.

PREFERRED QUALIFICATIONS

• Five (5) or more years of direct experience with infection control and safety program development, including AAAHC accreditation and survey preparation activities.
• Three (3) or more years of proven ability in the areas of leadership, healthcare regulations, infection prevention and employee health principles, education outcomes development.
• Certification in Infection Prevention and Control (CIC)
• Active professional licensure as a healthcare provider (e.g. MD, PA/FNP, RN, Pharm, etc.)
• Bilingual skills in English and the Keres native language.
• PRIOR EXPERIENCE WORKING WITH INDIAN HEALTH SERVICES (IHS), A TRIBE OR TRIBAL ORGANIZATION.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. Limited overnight travel may be required from time to time. This position may be exposed to certain health risks that are inherent when working within a health center facility.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors

and staff.