Job Description
Director of Quality Management and Infection Control/Prevention
Quality management seeks to improve effectiveness of treatments and increase patient satisfaction with the services provided. With an aging population and rising health care costs, quality management in health care is gaining increased attention.
The director of quality management and infection control and prevention for the Health and Wellness Center (HWC) will ensure the quality program has a patient centered focus with a goal of improving overall patient health outcomes for chronic disease management, reduction in hospitalizations and ED visits, public health screenings for disease prevention and education for clients and their families/caregivers with a focus on customer service and patient satisfaction, while striving to meet and exceed expected quality metrics through governing entities, payers and accreditation bodies.
EDUCATION AND EXPERIENCE/QUALIFICATIONS
Nursing degree from an accredited nursing school plus 5 years of clinical experience providing nursing services to patients from diverse economic and cultural backgrounds, as well as exceptional communication, interpersonal and organizational skills are required. Outpatient primary care settings experience preferred. Experience in healthcare quality and infection prevention and control preferred. Must have strong computer skills, working knowledge of data management software and excellent written and verbal communication skills. Bachelor’s degree in nursing, or other related IT/Data/Quality field.
Licensure Requirements for Clinical Positions
Credential(s) Required: Licensed as a Registered Nurse.
MISSION STATEMENT
Wheeler provides equitable access to innovative care that improves health, recovery and growth at all stages of life.
EMPLOYEE BENEFITS
Wheeler Clinic offers access to a comprehensive array of benefits, including:
For Good Health
- Anthem Medical, Prescription, Dental and Vision insurance
- Health Savings Account (HSA), with company contribution of $500 per year
- Wellness Programs
- Free annual flu shots
For a Secure Future - Company paid Life and AD&D insurance
- Company paid long-term disability insurance
For Retirement - 403(b) Plan, with clinic contributions for eligible employees
For Career Advancement - Education Reimbursement Program
- Training and development opportunities
For Work Life Balance - Generous paid time off, including vacation, sick and personal leave
- Employee Assistance Program (EAP)- Free and confidential counseling
Employee discounts at local spa and on cell phone services
ESSENTIAL DUTIES AND RESPONSIBILITIES
Infection Prevention and Control-HWC
Oversees compliance with accreditation and licensing standards for Joint Commission and state and federal requirements related to infection control and prevention standards, including maintaining a sanitary environment, hand hygiene program compliance, annual influenza vaccinations for patients, sterilization and disinfection of dental equipment, reportable diseases and medication safety.
Participate in committees such as health and safety, infection control risk assessment meetings and collaborate with the Quality Department for Wheeler Clinic including the Infection Control Coordinator. Participate in other committees as assigned.
Maintains an understanding of the facilities and populations served to review trends in diagnosis, demographics, care and treatment to assist with completion of annual risk assessment, as well as providing suggestions for new program development.
Maintains current industry knowledge in infection prevention and control standards and practices, epidemiology, infectious diseases, microbiology, disinfection/sterilization and emergency preparedness.
Establish infection prevention and control goals annually and evaluate and set new goals annually.
Plan, implement and evaluate infection prevention and control measures.
Perform investigation and surveillance of suspected outbreaks of infection and analysis and collection of infection control data. Compile data in an organized and easily understandable method for presentation to leadership and staffing groups to evaluate trends and report on plans for improvement and succession.
Educate and mentor individuals about infection risk, prevention and control methods.
Quality Management-HWC
Focus on needs of the patient, patient expectations for care provided and satisfaction with the service provided under the HWC health care system. Consistently monitor patient’s progress and participation toward goals and satisfaction with the service, as evidenced by diagnostic results of tests performed, self-management goal achievement and progress and engagement in care and services.
Establish performance goals, risk reduction procedures, quality improvement policies and procedures-review and implementation, quality measurement systems and reward mechanisms.
Work directly with VP Health Center Operations, Medical Director and clinical staff to gather, review trends and share UDS data; develop pertinent training related to requirements; chart audits for compliance and work with leadership team and clinical champions to encourage compliance and review best practices to improve outcomes and compliance.
Develop, revise and implement risk reduction procedures, quality improvement policies, quality measurement systems with IT and reward mechanisms for goal achievements.
Provides timely reports for quality committees and leadership in easily comprehended formats, inclusive of trending data and comprehensive analysis through use of Microsoft Excel.
Creates quality-related training materials specific for the Health and Wellness Center staff specific to department needs in a variety of learning modalities to educate staff on quality improvement initiatives; UDS data management, extraction and analysis; meaningful use measures, health outcomes trends and analysis and other topics as required and relate to quality improvement, best practice and patient outcomes.
Participation in the Joint Commission Accreditation Team meetings to prepare for ongoing accreditation surveys through review of compliance standards for the Health and Wellness Centers. Participates in system tracer activities, quality case reviews, utilizing root-cause analysis and Plan Do Study Act formulas to analyze outcomes, processes and policy, procedure and protocol compliance.
Participates in multi-disciplinary case reviews for patient related reported incidents as needed. Performs chart audit for time-line review of services provided in the HWC and works with the VP of Health Center Operations and/or Medical Director on discussion of findings and determination of action steps of patient related incidents.
Review policies and procedures, as well as protocols, related to quality and infection control and prevention under the direction of the VP of Health Center Operations. Review existing infection control, quality improvement policies and protocols annually and draft new policies as needed.
Collaborates with the Quality Department Leadership Team on quality measures, outcome reporting, accreditation standards and surveys.
Registered Nurse
Provides direct care to patients, as directed by a medical provider, including working directly with patients by getting their medical histories, monitoring vital signs, performing blood draws, preparing patients for diagnostic testing, performing diagnostic tests, dressing wounds, administering injections, screening and assessing calls, and assisting medical provider in the examination room.
Demonstrates strong nursing knowledge base and skill in job performance.
Assumes responsibility and accountability for coordinating care, in collaboration with the medical providers.
Ensures that continuity of care is maintained in all aspects of patient care.
Contributes to medical staff’s effectiveness by identifying patient care issues that must be addressed; providing information; recommending options and courses of action; and implementing medical providers’ directives.
Serves as liaison to medical providers.
Protects patients and employees by adhering to infection-control policies and protocols.
Documents patient care services by charting in electronic medical records.
Must be able to pass a respirator fit test at time of hire and on an annual basis.
Participates with regular staff meetings focused on coordinating care within an interdisciplinary team.
Performs job responsibilities consistent with standards for best practice nursing, including excellent communication with all providers to ensure the delivery of high quality care.
Continues to develop knowledge and understanding about the history, traditions, values, family systems, and artistic expression of groups served as well as uses appropriate methodological approaches, skills, and techniques that reflect an understanding of culture.
Demonstrates leadership by reinforcing positive behavior and promoting recognition through the use of effective employee evaluations, employee appreciation, effective hiring practices, and accountability.
Regulatory and Corporate Compliance Responsibilities
Understands and adheres to Wheeler Clinic’s compliance standards as they appear in the clinic’s Corporate Compliance Plan, Code of Conduct, and Conflict of Interest Policy.
Completes all training in a timely manner as required by state and federal regulations (e.g., Compliance, Fire Safety, HIPAA HI-TECH, Infection Control, Sexual Harassment, etc.) and specific to the department and position.
Keeps abreast of all pertinent federal, state and clinic regulations, laws, and policies as they presently exist and as they change or are modified.
Performs other duties as assigned.