Job Description

As a recognized infection prevention and control expert, leads the development, implementation, and evaluation of enterprise-wide strategies to reduce healthcare-associated infections and promote a culture of patient and workforce safety. Provides strategic leadership in healthcare epidemiology, surveillance, outbreak investigation, regulatory compliance, quality improvement, and evidence-based infection prevention practices. Partners with multidisciplinary leaders across the organization to assess and mitigate infection risks, develop policies and procedures, implement prevention initiatives, analyze and communicate surveillance data, and advance education, research, and innovation. Directs complex, high-impact programs and projects with organization-wide influence, serving as a trusted advisor to leadership while mentoring infection prevention professionals and contributing to the advancement of the field through scholarly activities, presentations, and publications. Applies advanced clinical and epidemiologic expertise to shape institutional policies, improve patient outcomes, and strengthen infection prevention practices across the health system

Department Overview

The Department of Hospital Epidemiology and Infection Prevention provides epidemiologic analysis based on the results of surveillance, risk assessment, communicable disease exposure follow-up, outbreak investigation, and other data; direct interventions at the patient, location, and service levels where needs are identified and where risk-reduction or change in practice is likely to have long-term success; education to personnel, patients and visitors with an emphasis on their role in infection prevention; thresholds of infection rates for surgical procedures and device-related infections above which department action is indicated; ensures regulatory, accreditation and legal compliance related to infection prevention issues.

Key Responsibilities

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

20

Y

Leadership:

1. Actively pursues collaboration and discussion by facilitating and leading diverse groups, welcoming opinions, respectfully challenging perspectives, and modeling effective listening skills
2. Encourages ownership of the process by group members, highlights group successes, builds a sense of shared accomplishment, and reinforces success by becoming an advocate for the group’s decisions
3. Develops annual plans and proposals to outline the overall infection control program structure and design for the medical center or system. Includes the goals and objectives and specific projects / action plans
4. Defines the process components and methodologies of the infection control program for the medical center or system.
5. Develops programs to contribute to an infection control structure.
6. Investigates and reports communicable diseases and other reportable events to appropriate agencies.
7. Establishes surveillance elements for inclusion in annual plan.

20

Y

Professional Stewardship:

1. Confidently performs a cost-quality analysis, performs negotiations, and presents to senior leadership for approval and implementation
2. Responsibly allocates and accounts for the use of fiscal resources, weighing alternatives and their benefits, and seeks ways to reduce cost; applies return-on-investment principles to establish the value of a product
3. Encourages own professional development and continuing education opportunities to maintain a broad range of expertise in patient-safety policies and industry best practices.
4. Mentors and coaches infection control professionals.
5. Leads training of newly hired Infection Prevention and Control staff
6. Develops and implements projects with interns/students

20

Y

Quality Improvement:

1. Establishes clinical metrics and outcome measures as determined by regulatory agencies or internal departments.
2. Develops and presents reports of findings, progress, and results of improvement efforts to key stakeholders and senior leaders to foster awareness of progress and potential barriers.
3. Advises management on highly-complex issues in infection control operations, including the development of new techniques, practices, and programs in clinical, educational, and training areas.
4. Collaborates with key stakeholders to assess the medical center or system regarding the benefits and risks of recommended actions.
5. Proficient in researching evidenced-based resources for risk reduction strategies; demonstrates ability to think laterally for appropriate actions

10

Y

Infection Prevention and Control Operations:

1. Establishes effective working relationships with stakeholders across the medical center or system to develop and implement actions to mitigate, reduce and prevent harm from potential and actual adverse events.
2. Evaluates the organizations’ compliance with infection control goals and other patient safety initiatives through the collection of data. Identifies areas for improvement, develops action plans and methods for assessing internal and external compliance with departmental leaders

15

Y

Infection Prevention and Control Informatics:

1. Is confident in their knowledge and skills to implement advanced epidemiology principles and statistics, data analysis, and the use of complex data communication and display and is comfortable using benchmarks to set up infection rate thresholds
2. Understands, selects, and uses advanced statistical and quantitative techniques and principles to achieve desired data or solutions
3. Conducts surveillance by whole and stratified patient populations.
4. Uses surveillance technology to develop and report data findings to guide facility strategy discussions with key stakeholders. The IP teaches and mentors others about the use of novel surveillance technology.
5. Creatively uses of the technology to generate unique and useful solutions to maximize the use of the technology.

10

Y

Research

1. Analyzes and interprets research, replicates research studies, and develops plans to implement and evaluate patient outcomes.
2. Demonstrates insight into the root causes of potential risks and generates a range of solutions and courses of action based on research; eliminates irrelevant and vague information, keeping the high-quality findings in focus; questions the limits, quality, and accuracy of data; perseveres for additional details; and confirms suspect data.
3. Seeks opportunities to collaborate with other experienced IPs to develop multisite studies and publications.

5

YOther duties as assigned

100%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

Knowledge, Skills and Abilities (KSAs)

Knowledge, Skills and AbilitiesReq / PrefDisplays expertise in infection control, including policies, regulations, surveillance, epidemiology, microbiology, patient care, and nursing. Conducts population-based surveillance, leverages technology for data reporting, guides strategy discussions, mentors others in novel approaches, and identifies innovative solutions to optimize technology use.Req

Demonstrates advanced expertise in infection control data management, analysis, research, reporting, and protocol development. Skilled in leveraging statistical techniques to drive solutions, analyze research findings, validate data accuracy, and implement risk reduction strategies while evaluating patient outcomes. Actively collaborates on multisite studies and publications to advance infection control practices.

ReqActively pursues collaboration and discussion by facilitating and leading diverse groups, welcoming opinions, respectfully challenging perspectives, and modeling effective listening skills. Demonstrates highly developed skills and expertise in organizational and project management. Leads teams and directs projects through from inception to completion on schedule. ReqImplements group building strategies in order to encourage ownership of processes by group members (e.g., highlights group successes, shared accomplishment) and advocates for the group’s decisions.ReqActively mentors colleagues through the continuum of Infection Prevention development; identifies developmental opportunities.ReqDemonstrates highly developed interpersonal skills, with the ability to advise and influence all levels of management and staff; strong diplomacy skills and ability to develop strong working relationships with external agencies. ReqDemonstrates highly-developed skills in written and verbal communications, with the ability to convey the most complex clinical, technical, and educational information in a clear and concise manner, and to produce high-quality reports, documentation, and presentations. ReqCollaborates effectively with management and staff across departments and to provide counsel and guidance on highly-complex issues of functionality, clinical quality, efficiency, and program development in all aspects of infection control. ReqEnsures responsible fiscal resource allocation, evaluates costs and benefits, advocates for prudent decisions, and applies return-on-investment principles to demonstrate value.ReqCompetently performs and presents cost-quality analyses to senior leadership for approval and implementation; capably negotiates for resources necessary to accomplish goals.ReqCapably investigates root causes of potential risks; generates a range of solutions and courses of action based upon research; demonstrates proficiency in reseraching evidence-based resources and appropriate actions, including the use of ideas from others or unconventional ideas, to develop solutions.ReqDemonstrates proficiency in developing risk assessments for unique situations; generates a collaborative team-based atmosphere to reduce risk and improve safety outcomes. ReqActively participates in local, state, national and international professional organizations in leadership positions; presents results of research, application of research and findings; provides guidance/ mentorship for colleagues in those organizations.ReqDemonstrates competency in Microsoft Word (create, format, save, edit using track changes, and print a document), Microsoft Outlook (create and send email, attach files, manage and organize messages and calendar), Excel (create a simple spreadsheet), Powerpoint (create, edit and present PowerPoint slideshows,), enter, manipulate and extract database information, and basic descriptive statistics e.g., Chi square, frequency analysis ReqMeets or exceeds all competencies of ICP4. ReqHas at least 8 years of experience in infection control, preferably in an academic medical center. Req

Special Conditions of Employment: (Statements identifying the fundamental non-negotiable job conditions and/or requirements which an individual must meet to be eligible for the position. For example, the ability to pass a background check, work in a particular environmental setting, work a flexible or irregular work schedule, etc.)

1. Rotates and adheres to after-hours on-call coverage.
2. Has at least 8 years of experience in infection control, preferably in an academic medical center.
3. Meets or exceeds all competencies of ICP4.
4. Competency in Microsoft Word (create, format, save, edit using track changes, and print a document), Microsoft Outlook (create and send email, attach files, manage and organize messages and calendar), Excel (create a simple spreadsheet), PowerPoint (create, edit and present PowerPoint slideshows,), enter, manipulate and extract database information, and basic descriptive statistics e.g., Chi square, frequency analysis
5. Ability to pass a background check.
6. Performs other duties as assigned.

Problem Solving

Common problems solved by the employee:

• Leads and manages all aspects of multiple enterprise-wide, cross-functional projects
• Identifies and applies appropriate risk reduction strategies to assigned or claimed projects/assignments
• Mentors earlier career colleagues

Less frequent and more complex problems solved by the employee:

• Negotiates for appropriate data display and dashboard functionality
• Leads assigned or claimed aspects of institutional epidemic/pandemic response

Problems/situations that are referred to this employee's supervisor:

• Fiscal negotiations with senior leadership
• Professional behavior issues

Management of Funds No

Does this position require oversight or management funds? No

Required Qualifications

• Bachelor's degree in Nursing, Public Health, Epidemiology, Microbiology, or another related healthcare discipline; or licensure as a healthcare professional in the State of California (e.g., RN, Pharmacist, Clinical Laboratory Scientist, Respiratory Therapist, Physical Therapist, or equivalent).
• Minimum of eight (8) years of progressively responsible infection prevention and control experience, preferably in an academic medical center or large, complex healthcare organization.
• Current California healthcare license (e.g., RN or comparable licensed healthcare professional)
• Current Certification in Infection Prevention and Control (CIC).
• Demonstrated expertise in healthcare epidemiology, infection surveillance, regulatory compliance, outbreak investigation, infection prevention program development, and quality improvement.
• Experience leading complex, cross-functional initiatives and partnering with multidisciplinary teams to improve patient safety and infection prevention outcomes.
• Advanced analytical, project management, and communication skills, including experience interpreting surveillance data, developing policies and procedures, and presenting findings to clinical and executive leadership.
• Proficiency with Microsoft Office Suite and infection prevention surveillance and data management systems.

Preferred Qualifications

• Master's degree in a health-related field, Public Health, Healthcare Administration, Business Administration, or related discipline.
• Doctoral degree (PhD, DNP, DSN, or equivalent).
• Experience leading enterprise-wide infection prevention programs within a large academic health system.
• Record of scholarly activity, including publications, presentations, or participation in multicenter research.
• Active leadership roles in local, state, or national professional infection prevention organizations.