SHIFT: No Weekends
About Del Sol Medical Center:
Since 1974, Del Sol Medical Center has provided quality healthcare to El Paso and the surrounding region. As a full-service, acute care hospital in East El Paso with a Level II Trauma designation in Emergency Services, we continue to expand our services to meet the growing needs of our tristate community, providing special expertise in Cardiology, Maternity & Child Services, a Level III NICU, a Center of Excellence designation for our Bariatric Clinic, a Level II Trauma Center, and a newly renovated 32-bed Rehabilitation Hospital.
The physicians, nurses and staff at our 350-bed hospital are committed to providing the highest quality care with compassion and integrity.
JOB SUMMARY (Primary
purpose of the position.)
Director of Infection Prevention is responsible for facility-wide activities of
evaluating and managing infection prevention risks to patients, visitors and
personnel through extensive surveillance and an effective reporting system. The
Director functions as the hospital and enterprise-wide clinical expert in the
prevention and Infection Prevention Plan of infection and is responsible for
the facility and enterprise -wide planning and implementation of the infection
prevention and Infection Prevention Plan program. The objective of the Infection
Prevention Program is to minimize both the risk of and the probability of
transmission of infection, thus providing a better and safer hospital for its
patients and personnel.? This position is
responsible for the coordination of the Infection Prevention Program.
GENERAL RESPONSIBILITIES (The essential responsibilities and accountabilities
of this position including interactions with other departments and outside
vendors, if applicable, in PRIORITY order:
- Works directly with the Infectious Disease Medical Director
- Develops, coordinates and manages the review and assessment
functions of the Infection Prevention program
- Initiates, develops and delivers education programs on Infection
Prevention and prevention for staff development and regulatory agency
- Represents the Infection Prevention program through membership on
hospital and medical staff committees;
- Serves as liaison and interfaces with all regulatory agencies, and
the health care community concerning infection prevention issues to assure
hospital compliance with infection prevention regulations
- Performs targeted surveillance and prepares reports and statistics
on healthcare-associated infection rates
- Develops and promotes consistent application of infection
prevention policies and procedures
- Supports emergency management activities and EOC through
participation on environmental rounds, bioterrorism and patient influx
planning, emergency response drills
- Identifies situations that may present an infectious hazard to
patients, staff, or visitors. Take appropriate actions to eliminate
- Identifies communicable disease cases to be reported to the
appropriate health department.
- Leadership abilities in
planning and implementing Infection Prevention Programs, and in serving in a
consultant/teaching role. Organizational ability in planning, coordinating,
& assessing data, and in making appropriate recommendations. Prioritize
projects and data collections to meet deadlines.
- Excellent verbal and
written communication skills. Intermediate level skills with Microsoft Office
(i.e. Word, Excel, PowerPoint, etc.)
- Ability to analyze recorded
hospital acquired infections, and to provide periodic trended statistics and
focused reviews to the Infection Prevention Team/Committees
- Coordinate and lead
quarterly activities/drills related to the HCA Infectious Disease Response Team
- Oversees and conducts
surveillance activities throughout all areas of the hospital.?
- Facilitates the integration
of principals of infection prevention and Infection Prevention Plan into the
planning a day-to-day activities of the hospital and evaluates risk for
infection at all campuses.
- Works flexible hours in
order to adequately meet the needs of employees working all shifts.
- Ensures education of
patient/family members is consistent and compliant with The Joint Commission,
National Patient Safety Goals, CDC Guidelines for Isolation, State and other
- Along with the nursing
staff, participates in patient and family education, based on learning needs,
abilities, leaning preferences, and readiness to learn based on age, level of
understanding, and cultural norms. Educates directors, managers and staff in
matters related to infection and disease transmission or prevention and in
isolation procedures and Infection Prevention and Infection Prevention Plan
- Conducts patient inspection
when requested by staff nurses, in regard to risk assessment of skin rashes,
shingles, or other potentially communicable disease processes present on
- Compiles statistical
database for reportable diseases. Submits data to the National Healthcare
Safety Network (NHSN) per state regulations, and CMS requirements.
- Examines microbiology
reports of positive isolates to recognize trends, identify hospital acquired
infections, and for statistical compilation.
- Conducts retrospective and
prospective chart audits to determine hospital onset or community acquired
- Instructs nurses, other
clinicians, and ancillary staff members regarding organisms and associated
risks to the environment, other patients, or staff members.
- Completes rounds of
clinical areas to identify patients who may have infections of epidemiological
significance. During rounds of clinical areas, identifies patient care
practices for compliance with acceptable Infection Prevention and Infection
Prevention Plan measures.? (i.e.-hand
- Participates in Department
Director meetings as subject matter expert in the prevention and Infection
Prevention Plan of infection(s).
- Maintains a working
relationship with contracted Hemodialysis Clinical Staff.
- Reviews water samples for
monthly water cultures of primary, secondary and portable dialysis water
Reverse Osmosis and/or Deionized systems. Reviews water specimen for annual
AAMI water quality standards testing. Reports all results of water cultures to
the Infection Prevention Committees on a quarterly basis.
- Works with Facilities
Management to correct any malfunction or positive culture/assay result.
- Works with contracted
nursing staff to ensure annual dialysate AAMI water sample compliance.
- Communicates patient care
needs with physicians and plans for appropriate interventions.
- Attends continuing
education programs to maintain or enhance skills and knowledge appropriate for
- Adheres to The Joint
Commission, CDPH, OSHA, CMS, and other regulatory standards.
- Monitors staff compliance
with Infection Prevention policies regarding the disposal of sharps and
biomedical waste. Monitors staff compliance with required personal protective
equipment. Monitors staff compliance with hand hygiene practices and provides
reports to the Infection Prevention Committees.
- Reports isolation activity
and problems involving Infection Prevention and the Infection Prevention Plan
to Nursing Leadership and the Infection Prevention Committees.
- Implements and revises Infection
Prevention plan and policies on an ongoing basis as needed.
- Conducts annual review and
revision of the Infection Prevention plan, establishing annual goals.
- Maintains Infection
Prevention patient databases (e.g. TheraDoc) in a HIPAA-safe method.
- Compiles infection rates
for surgical site infections, catheter associated urinary tract infections,
Adult and neonatal ventilator-associated events, adult and neonatal bloodstream
infections, C-Difficile infections, and other mandated infections. Reports monthly
results to Infection Prevention committees on a quarterly basis.
- Compiles additional
statistics or risk factors for infection on an ad-hoc basis.
- Participates with Plant
Operations and outside Contractors in completion of the ICRA (Infection
Prevention Risk Assessment) for all work within the confines of the hospital
- Conducts surveillance of
all maintenance / renovation or new construction work to identify ongoing risks
for patients, employees, and visitors to the facility.
- Monitors posting of the
ICRA permit on all construction/maintenance locations within the facility. Provides
in-service education to construction crew regarding the infection risks to
patients during construction and renovation.
- Collaborates with Employee
Health to maintain screening of workers (for TB, Flu or other communicable
diseases) who will work within the hospital environment.
- Maintains professional
contact with government and research agencies regarding infectious disease
Infection Prevention Plan.? Alerts
hospital personnel when a new disease has been identified; and measures to
reduce infection risk.
- Notifies physicians when an
inpatient has a known infection exposure.
- Monitors environmental
cleanliness of working areas and equipment in accordance with safety regulations
and basic Infection Prevention principles.
- Collaborates with Central
Services to monitor efficacy of sterilization and disinfection methods, rate of
immediate use sterilization, and documentation of sterilization logs used
throughout the hospital campuses.
- Monitors sterilization records and
conducts audits of sterilization or disinfection processes throughout the
EXPERIENCE REQUIRED?? (Minimum amount of specifically related experience which is required to perform the role at this level.
3 - 7 years
Other required experience: Minimum of 5-7 years? experience in specialty? ? ? ? with knowledge of epidemiology, microbiology, and principles of asepsis.
Other preferred experience: Five to seven years? acute care experience; experience in education and statistical analysis desirable
EDUCATION REQUIRED?? (Minimum formal academic training which
typically provides the knowledge and skills necessary for successful job
performance. Note in Other if experience may be substituted.)
Bachelor?s Degree-Major: Nursing
If not required, education preferred: MHA
Current license to practice as a Registered Nurse in Texas
or identified compact state
Required Upon Hire
(for certifications only: upon hire is defined as within 2 business days of
Current CIC Infection Prevention and Infection Prevention
Plan Practitioner certificate
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Associated topics: administrative coordinator, administrative officer, associate, chief operations officer, document, front desk, food, operations director, staff, support