Job Summary / Purpose

• The primary function of the Quality/Patient Safety/Infection Prevention Program Manager is to support, coordinate, and facilitate the quality management (QM), patient safety (PS), infection prevention (IP) and regulatory performance improvement (PI) activities for the hospital and medical staff. This role also serves as a resource to employees, management, nursing directors, senior management, councils, physicians and teams on quality management activities and will handle patient sensitive and confidential hospital information.

• Collaborates with the department leader in all infection prevention related activities associated with surveillance, performance improvement, and education which are intended to ensure that the facility’s patients, personnel, and visitors will be protected from transmission of diseases and infection within the facility’s environment as identified in the core competency model by the Association for Infection Control and Epidemiology (APIC).

Essential Key Job Responsibilities

• Assists in the design, planning, implementation and coordination of QM, PS, IP, and PI activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and root cause analyses and medical staff improvement (e.g. peer review, OPPE, FPPE). Clinical performance improvement, including case review for peer review.
• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures. Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.
• Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.
• Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers.
• Responsible for assisting the department to ensure compliance with Hospital Accreditation Standards, State and CMS regulations, and for the daily operations of the Infection Prevention Department. 
• Assists the department leader with ongoing assessment and development of programs, policies and procedures, and forms to address the Infection Prevention needs of employees, volunteers, contract workers, independent contractors, physicians, registry workers, and students in accordance with the guidelines established by the regulatory agencies.
• Oversees and monitors the clinical work of staff. Identifies competency and training needs. Coordinates and oversees training. Utilizes senior area staff to assist with training and provides clinical expertise.
• Identifies and implements updates to the Infection Prevention Program when new regulations and/or professional guidelines are published.

Minimum Qualifications