Northern Light A.R. Gould
Department: Quality Management
Position is located: Northern Light A.R. Gould Hospital -
Work Type: Full Time
Work Schedule: 8:00 AM to 4:30 PM
The Quality and Infection Prevention Specialist initiates and supports day-to-day functions, as well as strategic imperatives, that support infection prevention, quality, and performance improvement initiatives of Northern Light Continuing Care, Mars Hill.
The Quality Specialist’s scope of responsibly encompasses all departments of the nursing home. This individual will have detailed understanding of the AR Gould Hospital Quality and Patient Safety plans, as well as the Infection Prevention Annual report for Northern Light Continuing Care. The Quality and Infection Prevention Specialist will skillfully use the techniques of system design, reengineering, project management, quality improvement, outcomes measurement, and basic statistical analyses to advance goals and objectives of the plans. This position will also serve as the primary Infection Control resource for Northern Light Continuing Care site in Mars Hill, and will be based at this location.
Surveillance, Prevention and Control Program Development, Coordination and Direction:
·Under the leadership of the Manager of Infection Prevention and Quality, and in collaboration with the Infection Control Committee, designs and implements a surveillance plan and program objectives.
·Systematically collects data for the purpose of identifying and tracking high risk, high volume healthcare-associated infections and sources of infection.
·Makes recommendations for program and policy development for the prevention and control of infection and exposure to bloodborne pathogens among patients, visitors, staff, and all associates.
·Assists in the implementation of programs in order to meet compliance with State, , OSHA, and CDC guidelines and recommendations related to Infection Control. This includes assistance with the facilities “mock survey” procedures.
·Actively participates in and leads implementation of new initiatives.
·Promotes, implements and monitors an effective hand hygiene program that complies with the CDC guidelines.
·Adheres to State and Federal mandates, investigates, manages, and reports outbreaks of infection. Collaborates with Maine CDC as necessary.
·Assists with the review and revision of infection control policies/procedures to meet changing practices and standards in all organizational settings including hospital, outpatient dialysis, medical office practice, and nursing facility.
·Evaluates isolation techniques and assists with placement of patients as needed.
·Provides necessary infection control education for all employees when necessary.
2. Patient Safety Promotion:
- Develops patient safety strategies in partnership with system patient safety leaders, to be instituted across the organization. This may require partnership with the Senior Physician Executive, AVP of Nursing, or other leaders who can support and authorize new safety protocols.
- Reinforces a culture of patient safety through encouraging the reporting of near misses and patient safety events, and through the facilitation of the culture of patient safety survey and its associated action plans.
3. Quality Monitoring and Improvement:
- Actively participates in data collection and analysis of assigned projects
- Identifies trends from analyses.
- Actively participates on system and local improvement teams
- Supports the use of quality improvement models such as CUSP, and RCA2 to assist in the exploration of issues that may arise.
- Participates as needed in the staff development activities to support quality improvement activities.
- Responsible for the assistance with facilitation of mock surveys at the facility, as well as any follow up education and action plans as appropriate.
- In collaboration with providers and staff, assesses, develops and implements programs to meet the needs of all staff. This can include: hospital orientation for new employees; and train-the-trainer programs in aspects of infection control such as HIV counseling, or others as needed.
- Promotes, provides education, and monitors infection control and patient safety practices on an ongoing basis
- Performs rounds on all patient care areas at Northern Light Continuing Care for case findings and teaching purposes. Frequency based on prioritization of risk factors and identified trends/patterns.
- Participates in the development and review of standards of care, policies and procedures relevant to infection control and quality for Northern Light Continuing Care
- Serves as a resource in infection and exposure-related incidents and infectious and contagious disease related diagnosis.
- Maintains a collaborative relationship with the organizational safety officer and meets regularly to focus on shared responsibility for the design and implementation of interventions to decrease employee exposures/infections, improve quality and employee satisfaction
- Participates in the development of performance improvement metrics and projects related to infection control and quality.
- Provides direct patient consultation for complex infection control situations.
- Consults with health care providers concerning the delivery of care, which enhances desired patient care outcomes.
6. Outcome Evaluation:
- Works in conjunction with other members of the healthcare team works to evaluate and modify the plan of care based on achievement of patient outcomes.
- Collaborates with other members of the health care team to modify the plan of care as needed.
- Identifies and communicates potential quality concerns to the Manager of Infection Prevention and Quality or other colleagues at Northern Light Continuing Care.
7. Professional Practice/Leadership:
- Maintains patient confidentiality at all times.
- Represents the organization in a positive and professional manner in the community.
- Maintains regulatory requirements, including Joint Commission, Federal, and State laws and regulations.
- Complies with all organizational policies regarding Northern Light Health’s Code of Conduct and ethical business practices.
- Maintains and abides by ethical standards put forth by the facility and all licensing boards and professional organizations to which the employee is responsible.
8. Performs additional duties as required or assigned.
Competencies and skills:
* Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed.
* Acts Strategic: Creates effective plans that anticipate future consequences and opportunities and is able to connect the day to day operations to longer-term objectives, shifts in the industry, and system goals.
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Fosters Innovation: Employs and encourages the use of meaningful creativity in solving challenges. Proactively identifies opportunities and uses new approaches to enhance processes, systems and services. When appropriate, suggests or initiates new strategies, products, services, and markets.
* Database management application with the ability to create and maintain tables, develop forms and deliver reporting.
* Spreadsheet application with the ability to use calculations, formulas, graphing tools, pivot tables, and a macro programming.
* Word processing, spreadsheets, data entry, database experience and other computer related skills.
* Presentation software with the ability to create presentations with the ability to incorporate animation, audio, video, time delays, as well as designing themes and variants with animations and effects.
* Word process application with the ability to create and edit documents, format, use tables, apply footnoting, create table of contents and mail merge techniques.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
* Seeks Process Improvement & Applies System Thinking: Possesses and gains insight into situations, problems and processes. Understands the interconnection between organizational elements. Deconstructs problems and systematically investigates the various components. Considers the impact of actions on the entire process/system. Detects problems and opportunities, recognizes important information, and links various data to trace potential causes and relevant details.
Certified Professional of Healthcare Quality (CPHQ), LEAN, or Six Sigma preferred
Associate’s degree in health sciences, public health, healthcare administration, medical assisting, or related field. A degree in practical nursing would also apply. Bachelor's degree preferred. Must complete CDC’s Infection Prevention Training program within 60 days of hire if not already completed.
Must complete APIC Long Term Care Infection Preventionist Essentials 101 and 102 within 12 months of hire if not already completed.
Work experience & skills: A minimum of two (2) years working experience in infection prevention, quality, and performance improvement or project management; healthcare experience and knowledge of CMS Nursing Home regulation will be required.
Software and technology: MS products including Excel, MS Access, PowerPoint, and statistical software.
Ability to foster a cooperative work environment.
Excellent problem solving and communication skills.
Ability to perform statistical analysis and understand the appropriate applications of interpretive statistics, display of data using graphical techniques such as scatter plots, histograms, bar charts, trend lines, etc. preferred.
Team development and facilitation techniques applied to quality improvement or project teams to achieve their highest potential.
Organization and planning, managing multiple demands, and achieving results. Exceptional verbal, written, and presentation skills.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status