Manager Infection Control - Quality & Patient Safety - Kettering - FT/Days

Kettering Health is a notforprofit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with highquality care for every stage of life. Our serviceoriented mission is in action every day whether its by providing care in our facilities training the next generation of health care professionals or serving others through international outreach.

Kettering Health Main Campus

• Kettering Health Main Campus formerly Kettering Medical Center is the flagship hospital of Kettering Health and has been serving Kettering Ohio and the Greater Dayton area since 1964.
• The facility includes the Benjamin and Marian Schuster Heart Hospital maternity service with a level III neonatal intensive care unit (NICU) andlevel II Emergency Care.
• In 2020 KH Main Campus received an A from the Leapfrog Group a national patient safety watchdog ranking among the safest hospitals in the United States.
• Received 4 Star BabyFriendly Hospital status by the Ohio Hospital Association.
• Awarded as one of the 50 Top Cardiovascular Hospitals by IBM Watson Health in 2020.
• Kettering received the Outstanding Patient Experience Award by Healthgrades ().
• Accredited by the American College of Emergency Physicians as a Level 3 Geriatric Emergency Department.
• 465bed hospital (includes newborn beds)

Provides management and support in the development training and implementation of the campus InfectionPrevention and Control (IPC) Programs striving for One Best Practice across all KH Facilities. Serves asknowledge expert in IPC practice processes surveillance methodologies products equipment policies andregulatory and accreditation standards. With the Campus Directory of Clinical Quality and the Facilitys MedicalDirectory of Infection Prevention and Control provides oversite and direction to the facilitys InfectionPrevention and Control program to ensure compliance with all Federal State and HFAP requirements.

Minimum Education

• Bachelors Degree in Nursing (State of Ohio) or related healthcare field

Required Licenses

• Ohio United States Registered Nurse
• Active Ohio Registered Nursing Licensure or National licensure in Laboratory Science Epidemiology or otherclinical area required.
• Certified Infection Prevention and Control Upon hire or within 2 years of hire required

Minimum Work Experience

• Minimum of 1 year of progressive supervisory/leadership experience with demonstrated leadership andmanagement skills
• Maintains competencies and skills of IPC
• Ability to communicate effectively written and oral
• Ability to evaluate statistical data for use in planning and monitoring outcomes
• Ability to work under stressful situations
• Proven skills in developing high performance teams
• Proven skills in facilitating performance improvement teams to achieve best in class results

Work Environment

• Requires travel to all network facilities to complete facility rounds for issue identification processimprovement and standardization projects
• Fastpaced; juggling and prioritizing multiple projects at one time with altered hours to meet jobrequirements from time to time
• Frequent review and utilization of computer systems to review electronic medical records and developmentof action plans; research on best practice etc.
• Frequent formal meetings to present and/or review data that includes guiding teams to develop action plans
• Frequent support to hospital units and service areas where patient care is delivered to providepatient/family/staff education surveillance process reviews performance improvement measures etc

Key Job Responsibilities
This position serves as the Infection Control Officer (ICO) and as such requires knowledge of epidemiology andapplication of public health practices in an acute and outpatient care hospital environment with the goal ofimplementing effective and efficient procedures and policies to combat disease transmission among patientsand staff. Conducts scientific research to recommend implement and monitor policies and procedures forhospital staff regarding sterilization disinfection and decontamination of personnel instruments andequipment. Utilizes organizational resources to act as an advocate for the safe and timely delivery of care withaccountability for integrating services that facilitate One Best Practice for patient care related to Infection Prevention and Control issues.

• Provides support and expert guidance to the facilitys Infection Prevention and Control team for managementof the prevention investigation monitoring and reporting of the spread of diseases as follows:
• Develops and implements the facilitywide infection surveillance prevention and control policies andpolicies and procedures that adhere to nationally recognized guidelines and standards including theAccreditation Commission for Health Care (ACHC).
• Ensures that all documentation of the infection prevention and control program is completed including thesurveillance prevention and control activities.
• Communicates and collaborates with the hospitals Quality Governance Council on infection prevention andcontrol issues.
• Performs routine department rounding to ensure compliance with all infection prevention and controlpolicies and procedures as applicable and shares observations with appropriate leadership teams
• Participates in facility Environment of Care Rounds and documents findings appropriately
• Responsible for approving Infection Control risk assessments for construction projects weekly roundingand construction project closeouts in collaboration with the facilities management team
• Communicates and collaborates with the facilitys antimicrobial stewardship program.
• Develops competencybased training and education of hospital personnel and staff including medical staffand as applicable personnel providing contracted services in the hospital on the practical applications ofinfection prevention and control guidelines policies and procedures.
• Creates/ maintains processes to aid in the prevention and control of HAIs including auditing of adherence toinfection prevention and control policies and procedures by hospital personnel.
• Ensures the maintenance of a sanitary facility environment.
• Develops and implements infection control measures related to hospital personnel for infection controlpurposes. This includes all hospital staff contract workers (e.g. agency nurses housekeeping staff etc.) andvolunteers.
• Mitigates risks associated with patient infections present upon admission
• Mitigates risks contribution to healthcareassociated infections
• Establishes / maintains processes for active surveillance
• Monitors compliance with all policies procedures protocols and other infection control programrequirements.
• Evaluates the facilitys infection prevention and control program annually at minimum and revises theprogram when indicated.
• Coordinates as required by law with federal state and local emergency preparedness and health authoritiesto address communicable disease threats bioterrorism and outbreaks
• Ensures compliance with the reportable disease requirements of the local/ state/ national health authority.
• Routinely evaluates work processes customer service issues and job functions to ensure continuousimprovement
• Demonstrates willingness and exceptional ability to problem solve routine to complex situations
• Is a role model for Excellence for Life by demonstrating the Standards of Behavior that support KHN values(trustworthy innovative caring competent and collaborative)
• Personal Attitude leaves a lasting favorable impression on others
• Personal Communication creates positive encounters with others
• Personal Trustworthiness creates/maintains meaningful/enduring relationships
• Personal Innovation adapts personal actions/responses to advance personal level of service
• Personal Ownership reflects a ready willingness to Go the Extra Mile
• Personal Nurture anticipates needs of others and responds in a professional and emotionally supportivemanner
• Personal Sensitivity demonstrates a genuine concern and caring for others
• Exhibits a positive response to constructive criticism
• Attends Town Halls (4 meetings exceeds; 3 meetings meets)
• Uses medical center resources efficiently

Work Environment

• Requires occasional travel to other System facilities to complete facility rounds for issue identificationprocess improvement and standardization projects
• Fastpaced; juggling and prioritizing multiple projects at one time with altered hours to meet jobrequirements from time to time
• Frequent review and utilization of computer systems to review electronic medical records and developmentof action plans; research on best practice etc.
• Frequent formal meetings to present and/or review data that includes guiding teams to develop action plans
• Frequent support to hospital units and service areas where patient care is delivered to providepatient/family/staff education surveillance process reviews performance improvement measures etc.

• Masters Degree in Nursing or related Healthcare field preferred