QUALITY/RISK/INFECTION CONTROL MANAGER

Main Function

Contributes to the fulfillment of the organization's mission and philosophy by assisting in the analysis, implementation, and evaluation of the quality program. Responsible for the progress and maintenance of organization-wide performance-improvement, risk management, and infection control programs.

Duties and Responsibilities

1. Philosophy

Supports the facility's ideology, mission, goals, and objectives

Performs in accordance with the facility's policies and procedures

Follows the facility's standards for ethical business conduct

Conducts self as a positive role model and team member

Recognizes patients' rights and responsibilities and supports them in performance of job duties

2. General

a) Participates in facility committees, meetings, in-services, and activities

b) Punctual and comply with attendance guidelines

c) Gets along well with all employees and respects the rights of other employees

d) Demonstrates resourcefulness, independent thinking and seeks additional challenges and opportunities. Seeks to create new methods, techniques and processes.

3. Communication

Communicates effectively and professionally with vendors, physicians, coworkers, patients and visitors

Interacts with others in a positive, professional, respectful, and considerate manner

Checks and responds to emails in a timely and efficient manner

4. Financial practices

Uses facility resources appropriately and avoids wasteful practices

Reports wasteful practices

Analyzes work area and makes recommendations for potential cost-effective improvements

5. Compliance program

Assists in the implementation and maintenance of the organization's adopted compliance program

Performs according to established compliance policies and procedures

6. Safety/risk-management program

Adheres to safety policies and procedures in performing job duties and responsibilities

Reports observed or suspected safety violations, hazards, and policy/procedure noncompliance to the safety officer or other designated person

Complete annual education requirements

7. Professional competence

Participates in continuing education and other learning experiences

Shares knowledge gained in continuing education with staff

Maintains membership in relevant professional organizations

Seeks new learning experiences by accepting challenging opportunities and responsibilities

Welcomes suggestions and recommendations

8. Regulatory

a) Remains current on all applicable state and federal laws, rules, regulations, professional

standards and accreditation standards

b) Submits required reports on a timely basis

c) Develops, interprets and recommends implementation of policies, procedures, regulations, programs and recommended practices to ensure requirements are met

9. CQI/Performance-improvement program

Assists in the development and implementation of the organization's adopted performance-improvement program

Maintains and updates organization-wide performance-improvement programs, policies, and procedures

Performs according to established performance-improvement policies and procedures

Contributes to the performance-improvement process and identifies his or her role and contributions upon supervisor's request

Organizes and participates in committees, educational programs, and performance-improvement activities

Contributes to the evaluation of the performance-improvement program and recommends appropriate revisions, if applicable

Develops effective data collection, organization, and evaluation systems for monitoring the quality of patient care

Summarizes collected data and reports findings and recommendations in a timely manner to the performance-improvement committee

Coordinates performance-improvement activities and communicates outcomes to appropriate committees and individuals

Assists in the evaluation of patient, employee, and medical staff grievances to identify ways to improve patient care and performance standards

Identifies resources required for the performance-improvement program and submits resource requests to the governing body

Assists in identifying important indicators, establishing thresholds, and setting timeframe for evaluation

Maintains performance-improvement status log

Serves as an educational resource for performance improvement and keeps facility current on state and federal rules and regulations and accrediting-body requirements

Maintains performance-improvement records in a confidential and organized manner

10. Infection Control

Be familiar with facility policies and procedures

Surveillance, prevention, and control of infection

Identify and reduce risk of acquiring and transmitting infections among patient, employees, physicians and other independent practitioners, contract workers, students and visitors

Coordinate infection control programs and educates staff

Oversees and coordinates with Inservice Coordinator annual evaluation of TB on all employees

Maintain record of exposures, infections tracking and trending, quarterly documentation and reporting to quality Committee and the Governing Board

Ensures that all personnel/employees comply with infection control policies in conjunction with the Administrator

Continual monitoring of high risk and problem prone areas.

Work with staff/employees to analyze the patterns and trends to identify and determine whether a problem or opportunity for improvement exists

Qualifications

Cooperative work attitude toward co-employees, management, patients, visitors, and physicians

Ability to promote favorable facility image with physicians, patients, insurance companies, and general public

Ability to make decisions and solve problems

Preferred

Bachelor's Degree

Requirements

Education/Certificates/Licensure

Maintains current State of Florida RN licensure

Maintains CPR certification for Health Care Providers

Training/experience in performance-improvement/risk-management; certification preferred

Training/experience in project coordination

Training/experience in healthcare

Strong ethical and moral character references

Language skills adequate for high-level written and interpersonal communication