ABOUT NCH
NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.
NCH is transforming into an Advanced Community Healthcare System(TM) and we’re proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.
Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there's always more at NCH - for you and every person we serve together. Visit nchjobs.org to learn more.
JOB SUMMARY
The Director is administratively responsible for the leadership, development, implementation and management of the organization wide infection prevention and performance improvement programs. Through focus on engaging hospital leadership, quality improvement staff, clinical leaders, physicians and workforce, the Director works to achieve success in health care quality initiatives in strategic priority areas, while modeling inclusion and meaningful participation of patients and families.
Develops programs to improve quality and safety in the delivery of patient care services, utilizing data driven measurable across multiple healthcare facilities and assures the organization wide infection prevention and performance improvement initiatives. Utilizes surveillance, education, interventions and monitoring trends to successfully align processes for safety and quality improvement while maintaining all regulatory functions.
Oversees the Infection Prevention program and directs the surveillance of targeted patient populations in accordance with each Unit's Risk Assessment Plan. Oversees and coordinates reporting of communicable diseases and outbreaks of nosocomial infections to public agencies.
Oversees the Performance Improvement program, working with multidisciplinary teams including IT, Lean Process Improvement, Clinical and Business Leaders, Nursing, Physician, Compliance, Risk, and Education for process improvement.
Establishes continuous safety and performance improvement capacity and use of resources and supplies. Regularly reports the status of program efforts and impact of the organization Infection Prevention and Performance Improvement programs.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Other duties may be assigned.
· Assumes responsibility for and serves as a resource to each campus and Physician Office and Infection Preventionists on infection risk assessment, surveillance, prevention and control strategies.
· Responsible for ensuring that nursing leadership has current information on Joint Commission standards and federal, state, and county requirements pertaining to infection control and quality; functioning as a consultant to all hospital staff on infection prevention and quality issues; and being a liaison among the Infection Prevention/Quality Improvement Committee and other hospital departments.
· Reviews and analyzes infectious diseases laboratory reports and consults with the Nursing Administration team to ensure that aseptic techniques are incorporated into the individualized care plan.
· Prepares summaries of all resident/ personnel infections, corrective action taken, and the result of the corrective action. Shares summaries with Infection Control Committee and Nursing Administration team.
· Develops and maintains a system for detecting, evaluating, recording, and reporting infections which originate with NCH personnel.
· Develops and oversees orientation training programs for new employees and ongoing in-service education/training programs for current employees concerning all infection control and performance improvement issues, in conjunction with the Director of Education.
· Engages organizational leaders in the process of building, directing and implementing performance improvement activities to support the organization’s mission and vision.
· Creates, reviews and maintains Infection Prevention and Performance Improvement policy and protocol to maintain standards and compliance.
· Increases the PI capacity of the organization by evaluating and improving the effectiveness of the organization’s practices, partnerships, programs, use of resources.
· Establishes a continuous PI effort while utilizing a monitoring and reporting system to measure progress, impact and effectiveness.
· Ensure needed data for programs is collected, corrected and reported to internal and external (agencies) on a timely basis. Makes recommendations for future improvements based on data.
· Supports and implements organization wide programs improving the culture of patient safety through application of best practices and creating actionable intelligence. Leads efforts for organization’s collaborative networking with partner organizations and promotes an environment of shared learning and evidence based decision making.
EDUCATION, EXPERIENCE AND QUALIFICATIONS
·Graduate degree in a clinical field.
·Training and significant practical experience in clinical performance improvement, patient safety improvement, and quality outcomes measurement and reporting.
·At least 7 years of experience and progressive responsibility in health care leadership, including change management and leading complex, multi-stakeholder improvement initiatives.
·Preferred direct clinical practice experience in an acute hospital setting.
·Superb project management and organization skills. Must be able to set priorities and handle multiple, and sometime competing, tasks and projects; provides leadership and takes initiative; functions effectively with minimal supervision.
·Certification in Infection Prevention with minimum three years’ hospital experience in Infection Prevention
·Demonstrates a clear working knowledge of statistical methods, performance improvement processes and infectious disease and their impact on population health and safety.
·CPHQ preferred.
·Black Belt Certification preferred.
·Advanced knowledge of statistical analysis and reporting.
·Advanced capabilities with MS Office software (Excel, PowerPoint, etc.).
·Excellent presentation and communication skills.
·Demonstrated leadership ability to build and foster strategic relationships and develop and implement strategies.
·Intermediate computer knowledge: Uses Microsoft Word, Excel, Outlook, and Windows.
