At Houston Methodist, the NTW Infection Control/Performance Improvement Specialist is responsible for the development of performance improvement/patient safety initiatives and implementing and maintaining the multiple facets of the Infection Control Program. This individual maintains a routine surveillance program of patients, personnel, and the environmental problems that present a real or potential threat to the welfare of patients, visitors, or personnel throughout the institution. Promotes organization wide understanding of the overall quality and patient safety program and culture. Facilitates timely and effective resolutions of patient care issues. Serves as a resource to all levels of the organization relative to infection control and quality improvement activities, conducting or providing education as requested by staff or leadership. Coordinates teams as needed to drive change towards desired outcomes using appropriate performance improvement methodologies. Serves as a liaison between all departments and the Infection Control Committee.
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 10%
- Coordinates with others for the investigation, identification, and, as deemed appropriate, follow-up of contacts who are suspected or confirmed to have been exposed to relevant communicable diseases at Houston Methodist. (This activity shall include the notification of and follow through with the Employee Health Nurse when such contacts have involved hospital personnel.) (EF)
- Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data management/analysis functions to maximize outcomes. (EF)
SERVICE - 20%
- Uses national recognized definitions and best practice guidelines to maintain a practical surveillance program which incorporates the systematic and current review of healthcare associated infections (HAIs), significant communicable diseases, and environmental events with potential impact to patient, visitor and healthcare provider safety. (EF)
- Supports accreditation readiness initiatives. Participates in regulatory and accreditation surveys. Serves as system-wide resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences. Presents instructional material for orientations and continuing education relevant to infection prevention and control throughout the hospital. (EF)
QUALITY/SAFETY - 50%
- Routinely conducts infection prevention process surveillance to identify potential process deficiencies which may impact patient safety and lead to HAIs. Recognizes and investigates clusters of infections, communicates the investigation results through appropriate channels, and facilitates the implementation of interventions to prevent future infections. (EF)
- Abstracts pertinent information and enters into department databases using standardized methods and processes. Routinely performs discrepancy management activities to maintain data integrity. Presents meaningful reports and analysis with measurement description, statistical information, and benchmarking information. Reports data to external agencies as needed. (EF)
- Contributes to the evaluation (at least annually) and documents the effectiveness of the Infection Control Program Plan. Facilitates (at least annually) the revision of the Infection Control Program Plan to include new goals and measures as deemed appropriate based on a concurrent risk assessment. Develops and revises policies and procedures to meet current practice standards. Data mines information and produces statistics and reports in a meaningful way for decision making in support of continued infection prevention. (EF)
- Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators are met. Provides basic analyses of hospital performance against patient safety, quality and outcomes measures. Utilizes results from performance improvement activities to identify and prioritize areas of focus for improvement. Evaluates and provides input on the effectiveness of performance improvement programs. Conducts record review for performance improvement, peer review, patient safety, risk management and other projects. (EF)
- Supports improvement efforts for potential or actual quality of care/risk issues including participation/facilitation of Root Cause Analysis (RCA), Failure Modes Effects Analysis (FMEA), or event review as needed. Supports leadership and staff with the development and implementation of process changes. Summarizes events and presents findings as needed. Facilitates systems' design to hardwire patient safety processes. (EF)
- Supports facility construction planning and collaborates with construction through Infection Control Risk Assessment activities. Escalates safety and infection control issues in a timely fashion. (EF)
FINANCE - 5%
- Collaborates with other departments to monitor use of resources related to infection prevention. Participates in cost reduction efforts by making recommendations to mitigate risk of infection. Proactively identifies quality and safety improvement opportunities through analysis of internal and external data, to include federal incentive programs as applicable. (EF)
GROWTH/INNOVATION - 15%
- Responsible for facilitating and coordinating efforts aimed at implementing new standards as required by regulatory and accrediting agencies; including implementation of new or improved policies and procedures related to infection prevention. (EF)
- Designs, develops, and implements project plans related to strategic quality and safety initiatives. Manages reporting of these projects/measures to internal departments/committees and/or outside agencies, as needed. Provides oversight for these projects to ensure desirable outcomes are met. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
- Bachelor degree in Nursing required
- Three years of experience in a hospital or outpatient clinical role
- One year of experience in a quality management and/or patient safety, risk management, infection control, decision support or similar information analysis role
- Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements.
- Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, or Certification in Infection Prevention and Control preferred