Dir of Infection Control & Quality Improvemnt

INTRODUCTION

The Director of Infection Control and Quality Improvement is a qualified individual with knowledge of CDC guidelines and definitions of healthcare-associated infections (HAIs), quality improvement strategies and processes, NCCHC and ACA compliance and auditing, as well as federal and state infection control regulations. Responsible for the identification, investigation, reporting, prevention, and control of healthcare-associated infections (HAIs) among patients and personnel. Responsible for the operation and coordination or quality improvement programs at the Department of Corrections. Responsible for assisting with in-service programs related to Infection Prevention and Control and Employee Health.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

The Infection Control and Quality Improvement Director is responsible for promoting health and safety among all employees by carrying out the Quality Improvement, Infection Control, and Employee Health Programs. Under the supervision of the Medical Director of Correctional Health, this employee interfaces with all departments and services, and is responsible for identifying, controlling, and preventing outbreaks of infection and managing the operations and coordination of quality improvement and NCCHC and ACA compliance in the Central Detention Facility (CDF) and the Central Treatment Facility (CTF). This position plays a vital role in ensuring the delivery of high-quality healthcare to incarcerated individuals, compliance with healthcare standards, and continuous improvement of healthcare practices.

Administrative and Leadership

• Responsible for providing Medical Director of Correctional Health with information and reports as needed to prepare for annual budget.
• Supervise, coach, and develop Quality Improvement Specialist and Procurement Specialist.
• Will participate in committees as requested.
• Collaborate with department managers and DOC leaderswhen needed.
• With the Medical Director of Correctional Health, oversees quality and performance improvement activities.
• Maintains summaries and written reports required for quality improvement and employee illness/injury reporting.
• Attends workshops and trainings on employee health/infection control and OSHA guidelines.
• Orders and maintains an adequate supply of all necessities for the employee health program.
• Implements program goals and policies that have been established by the medical and administrative directors.
• Responsible for making direct contact with the Medical Director of Correctional Health when calling in due to illness or emergency.
• Other duties as assigned.

Quality Improvement

• Oversee day-to-day operations of the quality improvement program, under the guidance of the Medical Director of Correctional Health.
• Assist in the development and implementation of the DOC quality improvement program and annual quality improvement goals and plans.

• Collaborate with the Medical Director of Correctional Health and other department directors to address quality improvement and population health management goals, identify focused areas for improvement and implement strategies necessary to increase compliance of identified measures.
• Develop and revise data collection procedures and methodology to monitor health outcomes, patient safety, and conmpliance with standards and requirements.
• Work with DOC leadership team in setting goals that align with Unity’s organizational goals and national recommendations.
• Collaborate with DOC leadership, managers and Quality Improvement Specialist to analyze data and identify trends, patterns and areas for improvement.

• Support the Quality Improvement Specialist in training and provide ongoing support to managers and staff to conduct Plan, Do Study, Act (PDSA) cycles and other recognized approaches to test change as part of quality improvement efforts.
• Collaborate with applicable directors and DOC leadership to prepare for, participate in, and help develop responses to findings in site visits and compliance audits, including NCCHC and ACA.
• Oversee the maintenance of NCCHC and ACA accreditation and compliance documentation.
• Oversee the collection and submission of performance metrics and reports.

Infection Prevention and Control

• Coordinate and lead both the Infection Prevention and Control Committee as well as the Infection Control Team.
• Serve as a knowledgeable and available resource on infection control practices and policies to patients, families, staff, and employees.
• Maintain compliance with national and state/ District standards and regulating bodies. Develop and update policies and procedures in accordance with current standards of practice, rules, and regulations.
• Conduct surveillance and follow-up of employee exposure to communicable disease.
• Collaborate with local health departments in conducting surveillance and follow-up of employee exposures to communicable diseases.
• Promote understanding and educates staff on relevant Unity Health Care policies and clinical protocols.
• Collaborate with the clinical trainer to coordinate training for clinical staff as necessary, based on needs and established protocols.
• Prepare clinical audits according to agency protocols and guidelines.
• Identifie and report concerns regarding provider performance directly to Chief Quality Officer.
• Conduct environmental rounds in all patient areas.
• Ensure all controls and regulations are met according to CLIA standards and policies for Unity Health Care and works with laboratory coordinator to maintain compliance.
• Other duties as assigned.

Employee Health

• Responsible for monitoring, inspecting and reporting safety hazards, facility needs and recommended improvements as related to infection control and employee health.
• Responsible for monthly and quarterly site inspections and conducts all required drills and inspections.
• Assure new employees are trained on OSHA regulations and environment of care.
• Plan, organize, develop and implement educational programs for all employees including administrative and ancillary services, which convey special knowledge and skills to increase employee awareness of existence of infections; techniques for avoidance and preventive measures to ensure a safe environment.
• Provide applicable immunization and Infectious Disease screening for all new employees
• Perform tuberculin skin testing of employees as appropriate.
• Provide Return-to-Work guidance for employees who may have infectious disease or exposure to infectious disease
• Provide education, training, and development of staff on topics such as infectious disease, chemical exposure and the use of personal protective equipment. Document training efforts and evaluate the effectiveness of such programs by administering post-training assessments.
• Refer employees with identifiable limitations and/or health risks to appropriate resources.
• Collaborate with Human Resources to ensure completion of all health screenings
• Other duties as assigned.

MINIMUM QUALIFICATIONS

• Bachelor’s Degree or higher in relevant field (e.g., microbiology, nursing, public health, or clinical degree) from an accredited college or university.
• Registered Nurse (RN) license active in the District of Columbia
• Five (5)years of infection control, employee health, or occupational health experience in employee health clinic, infectious disease or internal medicine clinic.
• Five (5) years of experience conducting continuous quality improvement and compliance coordination
• Certification in Infection Prevention and Control (CIC) from the Certification Board in Infection Control and Epidemiology (CBIC) preferred.

RISKS

The position’s work involves everyday risk and discomforts, which require normal safety precautions typical of such places as offices, meetings, training rooms, and other UHC sites. The work area is adequately lit, heated, and ventilated. The employee shall provide evidence of a recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.