Wilbarger General Hospital

Vernon, Texas

Job Description

Job Title: Infection Prevention/Nurse Educator/Employee Health and Risk Management

Department: Nursing Administration

Job Summary: Responsible for the Infection Prevention Program, including the surveillance, analysis, and reporting of healthcare acquired infections; educating employees about infection control; and the development of health system policies and procedures to insure rigorous infection control standards that meet regulatory and accrediting requirements. Assessment, planning, implementation, and evaluation of education programs for all hospital employees.

Job Qualifications:

A. Education: Graduate of accredited registered nurse program. BSN preferred. MSN desirable.

B. Personal Job-Related Skills: Basic understanding of medicine and disease processes as well as WGH functions. Knowledge and abilities in teaching adult education. Effective oral and written communication skills. Leadership and management skills. Basic computer, data collection, and information evaluation skills. Knowledge of Infection Prevention standards. Knowledge of Employee health processes. Knowledge of risks inherent to healthcare and methods to mitigate risk and reduce unsafe practices.

C. Licensure, Registry or Certification: Registered Nurse currently licensed by the State of Texas Board of Nursing. BLS and ACLS required.

D.  Experience:

1. Prior work experience: At least three years previous experience as a Registered Nurse in a health care setting with experience in infection control and/or employee health programs preferred. Working knowledge of microbiology, epidemiology, infectious diseases, aseptic techniques, current practices and professional standards preferred.

E. Physical and Mental Requirements: Intermittent sitting, prolonged periods of standing and walking. Frequent bending, stooping, twisting, reaching. Average lifting of 25 pounds, with occasional lifting up to 50 pounds. Pushing and pulling with 50 pounds force while assisting patients or moving equipment. Occasional heavy lifting when moving or supporting patients who may become weak or helpless.

Essential Duties and Responsibilities:

A.  Infection Control:

  1. Develops and implements departmental policies and procedures related to infection control. Reviews and revises policies as needed.
  1. Develops and Implements an Infection Surveillance and Prevention Plan annually.
  1. Develops and implements a system for identifying, investigating, reporting, and preventing the spread of nosocomial infections among patients of all ages and healthcare personnel.
  1. Conducts on-going surveillance using Center of Disease Control (CDC) criteria. Documents and investigates through review of:
  1. Healthcare acquired infections
  2. Admission diagnoses
  3. Microbiology culture results
  4. Isolation orders
  5. Patient records
  6. Temperature charts
  7. Consultation requests
  8. Post-discharge surveillance
  1. Reviews cultures and sensitivities reported by microbiology laboratory of patients and personnel to determine if infection is nosocomial in origin.
  1. Confers with staff nurses on all patient units on a regular basis to determine if infection is nosocomial in origin.
  1. Investigates infections, especially those occurring above established thresholds, and/or clusters by patient units.
  1. Initiates culture and sensitivity and/or appropriate isolation precautions when indicated.
  1. Provides in-service education related to infection prevention and control system wide.
  1. Completes and submits required reports to the Texas DSHS and NHSN in a timely and accurate manner.
  1. Maintains accurate records of nosocomial infections among patients and personnel.
  1. Ensures proper use of germicides, cleaning products, antiseptics, and disinfectants throughout the facility.
  1. Monitors methods of asepsis, sterilization, and disinfection employed throughout the facility.
  1. Communicates infection surveillance activities to QAPI and administration via the Clinical Review Committee and medical staff via the Medical Staff meetings.
  1. Collaborates with the Chief Nursing Officer to review and approve Infection Prevention Manual, policies and procedures at least every two years.
  1. Stays informed of changing infection control standards and practices and presents plan for compliance in a timely manner.
  1. Designs and implements new methods to improve the efficiency and outcomes of the Infection Prevention Program.
  1. Implements and conducts special studies when appropriate.

B.  Nurse Educator/Employee Health:

  1. Maintains standards of nursing practice by providing education in clinical nursing activities.
  1. Reviews education requirements with WGH department managers and supervisors.
  1. Conducts annual needs analysis to facilitate formulating education goals and objectives for WGH staff.
  1. Familiar with all clinical policies and educates staff on such policies.
  1. Together with core measure abstractor, will assist in developing compliance tools and staff education.
  1. Will assist in customer service education initiatives.
  1. Works with local nursing programs to establish clinical rotations as well as overseeing observation program.
  1. Investigates and evaluates new healthcare developments. Recommends and implements initiatives that improve patient care.
  1. Develops, maintains, and reviews employee education records and reports on employee participation in education programs.Provides information for program evaluation. Schedules required education for all WGH employees.
  1. Participates with the Chief Nursing Officer in assessing data concerning quality of patient care for clinical departments.
  1. Coordinates processing of new employees with human resources department.
  1. Monitors employee injury variances and illnesses for trends.

C. Risk Management:

1. Identify, prevent, reduce and manage actual or potential sources for

harm or financial loss.

2. Review incident reports and delegate investigation process to affected

department.

3. Analyze, trend and evaluate results and oversee corrective action

plans.

4. Report risk situations to appropriate agency and/or leadership team as

necessary.

5. Educate employees on risk identification and reduction strategies.

Other Significant Requirements:

A.  Maintains confidentiality while working with confidential matters on a daily basis.

B.  Provides service direct to employees and/or patients while maintaining a positive employee and/or patient relations atmosphere.

C.  Interacts with patients, family members, Medical Staff members, department managers, and other staff on a continuous basis.

D.  Utilizes aseptic procedures and maintains standard precautions when involved in direct patient contact or handling potentially infectious materials.

E.  Ensures that licensure and certifications are kept current and in accordance with state laws and hospital policy and appropriate continuing education is attended for CEU requirements.

F.  Keeps current with new healthcare developments by attending educational offerings and literature reviews.

G.  Complies with accrediting agency recommendations.

STATEMENT OF UNDERSTANDING:

I have read and understand the above JOB DESCRIPTION and understand the essential duties outlined and required in this position. I understand that I should contact my Department Manager if I have any questions or concerns regarding the job duties and requirements as outlined above. I acknowledge that I have received a copy of this job description.

Employee Signature Date

Department Manager Signature Date

Revised 03/01/2016