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QUALITY COORDINATOR/INFECTION PREVENTION CONTROL RN

Company: Universal Health Services, Inc.
Location: Spokane
Posted on: April 3, 2024

Job Description:

Responsibilities

REPORTS TO: Director of Nursing/Compliance Office SUMMARY STATEMENT & PURPOSEThe Infection Control Nurse (RN) is responsible for planning and coordinating the activities of the Hospital's infection control program, by assuming direct responsibility for infection surveillance, documentation, infection control reporting, and provision of infection control technical support and education for the hospital staff. The Infection Control Nurse will develop and maintain the Infection Control Plan as well as policies and procedures to support all current standards and rules. Will maintain current practice through participation in workshops, in service, and staff development. Will maintain current practice through participation in workshops, in service and staff development. The Quality Coordinator is responsible for monitoring, collecting, and analyzing the facility-wide performance management program, ensuring the facility's programs are in compliance with all the regulatory agencies and state and federal agencies. Maintains upkeep of policies and procedures through Policy Stat including new and updated forms and notifies leaders of for review and approval. Maintain an ongoing working and respective relationship with fellow employees. All employees are expected to be pleasant, respectful, and courteous in all interactions with patients, families, staff, and visitors of the Hospital, as well as being a positive representative of INBH at all times. MINIMUM QUALIFICATIONS

  • Graduate from an accredited program of professional nursing
  • Current RN license to practice by the State Board of Nursing/Nursing Commission.
  • BLS, Handle with Care, and Verbal De-escalation certification, provided by the facility..
  • Knowledge of Joint Commission/CMS, OSHA, State and Federal regulatory requirements. PREFERRED QUALIFICATIONS
    • Bachelor's Degree preferred.
    • A minimum of three (3) years' of charge nurse/leadership experience preferred. Management, nursing education, and infection control experience in a psychiatric healthcare environment is also preferred.
      Qualifications

      SPECIFIC PERFORMANCE RESPONSIBILITIESAll functions are essential functions unless otherwise noted.The job functions of this position are not limited to the duties listed below.
      • Infection ControlA. Monitor employee and patient health activities and illnesses which includes:-Maintain a method of identifying and recording known or suspected infections in patients and employees.-Coordinate with all departments to obtain information regarding patients and staff with suspected infections and conduct periodic inspections to ensure that procedures for the control of infections are implemented and adhered to.-Respond to problem situations in an urgent manner and report the number and type to the Infection Control Committee.
        • Monitor and evaluate the use of personal protective equipment and perform all fit testing for all staff.
        • Perform monthly monitoring and evaluate the storage and disposal of infectious wastes such as used sharps and body fluids.
        • Perform all required monthly infection prevention control monitors. Report all findings of infectious communicable diseases through internal and external monitoring systems.
        • Prepare monthly reports to the Safety/Risk Management Committee, Infection Control Committee, Medical Staff Committee, and Nursing Administration Committee that includes data on infection rates by nursing units, site, and pathogen.
        • Document and report any infection updates or statistical data to leadership as requested.
        • Organize Infection Control Committee Meetings and maintain all meeting minutes.
        • Act as a consultant in infection control for the Nursing Department by assisting with assessing patient infection control problems, planning and evaluating the care of the patients.
        • Alert CMO regarding any actual or suspected infection that may impact hospital or medical staff function and processes.
        • Notify the County and/or State Health Department/Board of any reportable diseases, adhering to all internal county and state procedures.
        • Act as a liaison between the State/County Board of Health, and the Health Department.
          • Employee Health
          • Completes Employee Health visits per organization policy and department protocols.
          • Provides safe, competent and efficient nursing care for minor and acute injuries and illnesses via protocols and medical directives.
          • Monitors employee work-related illness and injury trends and assesses, develops and implements strategies to prevent work-acquired injury or illness and expedite return to work.
          • Performs blood borne pathogen exposure assessment, treatment and follow up.
          • Participates in preventative screening programs (e.g. TB skin testing, influenza, hepatitis B, MMR, varicella and other appropriate immunizations) and surveillance programs designed to identify and monitor risks to the employee's health.
          • Safely administers and appropriately documents on immunizations and TB skin tests given to all employees per protocol, providing screening to Human Resources to maintain compliance with employee file.
          • Perform communicable disease exposure follow-up.
          • Maintains and ensures confidentiality of patient information and medical records.
          • Act as an advocate for the rights of employees by ensuring access to preventative health and safety measures.
          • Quality Coordinator
          • Assist Compliance Officer with Senior Management and Directors in the development of department performance improvement quality measures. Help leadership develop a Facility-wide and Intensive Outpatient Program performance improvement plan which meets regulatory standards by establishing a system for collecting and analyzing data related to performance improvement measures.
          • Provide training to staff members on the concepts of performance improvement and the application to patient care via orientation of all new hires.
          • Maintain a list of hospital-wide performance improvement indicators which includes monthly and quarterly data.
          • Presents set data at the performance improvement meeting and prepares performance improvement committee minutes.
          • Assists the Compliance Officer to ensure regulatory readiness and assists with preparing for Joint Commission, state licensing, CMS or other agencies. Assists in quality improvement activities and methods to track implementation of action plans following site surveys.
          • Ensure that the facility is in compliance with all HBIPS/IPFQR Quality Measures and completes monthly reporting. Monitor and report to the Compliance Office on results, including any areas needing improvement.
          • Submit monthly indicator information for the Clinical Services Dashboard. Develops, evaluates, analyzes, and maintains quality dashboards and performance metrics.
          • Yearly letters to contractors, contractor log and ensuring contractors have correct education.
          • Enter BTAG data into Midas and provide results to all Department heads monthly.
          • Complete and submit all facility licensure in a timely manner to maintain compliance.
          • Assist department leaders in creating their action plans for any necessary corrections post site/survey response. Report all draft plans of correction to the Compliance Officer for review and final submission.
          • Update all required progress reports and submit to Compliance Officer.
          • Audit charts for Healthcare Disparities screenings and present data quarterly to PI committee.

Keywords: Universal Health Services, Inc., Spokane , QUALITY COORDINATOR/INFECTION PREVENTION CONTROL RN, Healthcare , Spokane, Washington

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