Director of Infection Prevention & Control

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Job ProfileSummary

​This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. In addition, this role focuses on performing the following Infection Control duties: Prevents healthcare-acquired infections (HAIs) by isolating sources of infection and limiting their spread. Responsibilities also include systematically collecting, analyzing and interpreting health data in order to plan, implement, evaluate, and disseminate appropriate health practices. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that directs a department or small unit that includes multiple teams led by managers and/or team Leaders. Responsibilities typically include: ownership of short to mid-term (1-3 years) execution of functional strategy and the operational direction of the Department, problems faced are often complex and require extensive investigation and analysis, and requires ability to influence others to accept practices and approaches, and ability to communicate and influence executive leadership.

Job Overview

This position oversees the organization's Infection Prevention and Control program, Safety program, and Occupational Health Services. Ensures compliance with hospital regulatory standards, including the Massachusetts DPH, CMS, OSHA, The Joint Commission, EPA, DEP, NFPA, and other federal, state, and local health and safety standards. Manages a team of professionals, serves on committees, and works collaboratively on building health and safety programs according to the goals, philosophy, and objectives of the organization.

Minimum Qualifications:

1. Bachelor's Degree in Safety, Environmental Management, Nursing, or Public Health.

2. Five (5) years of experience in hospital safety, Environmental Health Services Management, Infection Control and Prevention, and/or Occupational Health and Safety.

3. Certified in Infection Control (CIC) OR Massachusetts Registered Nurse (RN) Licensure.

4. Hazardous Waste Operations and Emergency Response Standard (HAZWOPER) Certification OR Obtain within six (6) months of hire.

Preferred Qualifications:

1. Ten (10) years of experience in hospital safety, Environmental Health Services Management, Infection Control and Prevention, and/or Occupational Health and Safety.

2. Relevant Safety Certification(s) including: Certified Safety Professional (CSP), OSHA Certification, Healthcare Environmental Manager (HEM), Associate Safety Professional (ASP), or Certified Professional in Healthcare Quality (CPHQ).

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Identifies elements related to and implements the Infection Control Program specific to hospital population served at campuses within scope of influence.

2. Establishes, implements, and manages the hospital's Environment of Care (EOC) program.

3. Guides leaders to ensure compliance with Fire Safety, Safety & Security, Hazardous Waste & Materials, Medical Equipment, Utilities and other physical environment requirements to ensure the safety of all parties.

4. Ensures surveillance activities in accordance with the programs.

5. Evaluates the physical environment to identify and eliminate risk to patients, staff and visitors. Implement appropriate controls to minimize risk when necessary.

6. Conducts organization-wide environmental risk evaluation to quantify risk and develops action plans in response to any domain identified as high risk.

7. Develops new policies and procedures for changes in requirements of any regulatory body and new program or service.

8. Provides information to leadership groups, committees, and other forums as necessary for ongoing improvement.

9. Acts as a resource to all staff on health, safety and infection prevention and control practices and policies.

10. Supports through attending or leading as Chairperson Infection Control, Infection Prevention, Safety, and other forums.

11. Participates in Emergency Management Planning, activities, and simulations.

12. Evaluates new and existing facility projects and coordinates with stakeholders to initiate interim life safety measures, as warranted.

13. Ensures review and response to all safety incidents submitted though the hospital safety reporting system.

14. Ensures review of Safety Data Sheets (SDS) for new hazardous materials introduced into the organization and provides safe handling and storage guidance to staff. Uploads SDS into the online SDS library.

15. Objectively evaluates requests for process changes and environmental modifications and coordinates a risk assessment with stakeholders to identify potential risks and document rationale for decision making.

16. Responds to all inquiries from hospital staff and provides technical guidance as necessary, to promote compliance with hospital policy.

17. Develops content for annual competency training to cover Environment of Care, Infection Prevention, and Occupational Health requirements and other pertinent topics.

18. Responds to inquiries, surveys, and on-site visits from regulatory agencies, and develops and submits required reports and responses, as appropriate.

19. Identifies patterns or trends based on the data collection and analysis and develops response and action plan to any outbreaks identified.

20. Reviews and revises policies as appropriate.

21. Ensures investigation of events and works collaboratively with respective departments to provide guidance and implement corrective measures, to resolve hazards and minimize risk as necessary.

Physical Requirements:

1. Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.

2. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

3. Requires ability to see computer screen and reports.

Skills & Abilities:

1. Knowledgeable of Joint Commission accreditation standards and CMS Conditions of Participation.

2. Ability to serve as content expert for development and implementation of infection control standards.

3. Ability to develop and deliver training sessions according to principles of adult lea.