SUMMARY: The Infection Preventionist (IP) in conjunction with the Infection Control Committee develops, coordinates, implements, maintains, and oversees the hospital wide infection control program to prevent and/or control infection among patients and employees and to comply with requirements of The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS) Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), and the California Department of Public Health. Collaborates with Nursing, physicians and all ancillary departments of the medical center. Performs related duties as required.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. ATTENDS ALL REQUIRED SAFETY TRAINING PROGRAMS AND CAN DESCRIBE HIS OR HER RESPONSIBILITIES: Attends all required safety education programs. Provides complete and accurate responses to safety questions. Operates assigned equipment and performs all procedures in a safe manner as instructed. Maintains work area and equipment in condition required by department standards. Demonstrates proper body mechanics in all functions.
2. COLLECTS AND REPORTS DATA TO NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): Maintains a current digital certificate and completed NHSN training for Hospital Acquired Infection surveillance and data input. Reports data accurately to NHSN.
3. COMMUNICATES WITH LOCAL HEALTH DEPARTMENTS, HOME HEALTH AGENCIES, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES, AND OTHER AGENCIES TO PREVENT THE SPREAD OF INFECTION WITHIN THE COMMUNITY: Reports communicable disease information on a timely manner. Assists in an outbreak (communicable disease) investigation.
4. COUNSELS AND PROVIDES GUIDANCE AND RESOURCE DATA TO SUPERVISORS, DEPARTMENT MANAGERS, MEDICAL STAFF, PATIENT, AND/OR FAMILY MEMBERS REGARDING INFECTION CONTROL ISSUES: Utilizes appropriate resources within the infection control department to provide current update information to patient, students, and medical and nursing staff when requested. Provides information to patient and family members when asked for counseling. Supports policies and procedures with concurrent information and shares this with all departments as needed.
5. DEMONSTRATES RESPECT AND REGARD FOR THE DIGNITY OF ALL PATIENTS, FAMILIES, VISITORS, AND FELLOW EMPLOYEES TO ENSURE A PROFESSIONAL, RESPONSIBLE, AND COURTEOUS ENVIRONMENT: Fosters a professional working environment by assuming a leadership role (not supervisory) for all staff. Functions as a role model to the medical center. Interacts with all of the above in a considerate, helpful, and courteous manner as observed by manager and peers. Fosters mature professional relationships with fellow employees in a courteous, friendly manner as measured by management observation and peer input. Maintains professional composure and confidence during stressful situations. Maintains open communication using appropriate chain of command regarding issues. Conducts all work activities with respect for rights and wishes of patients, visitors, families, and fellow employees. Maintains confidentiality of all hospital and patient information at all times as observed by peers and management. Presents a neat and professional appearance in proper attire with identification badge visible at all times as required by department, and administrative policy. Continuously displays a "can do" attitude within the department and across departmental lines to contribute to the overall customer service and satisfaction program.
6. DEMONSTRATES THE BEHAVIORS AND ACTIONS THAT WILL FULFILL ALAMEDA HEALTH SYSTEM'S VISION: Demonstrate excellence in clinical quality and service. Become the preferred health care employer in Alameda County. Develop clinical programs that advance the health of Alameda County residents. Foster a culture of innovative, efficient, and customer-oriented care. Develop partnerships to provide a continuum of services responsive to the community. Provide compassionate and culturally sensitive care. Support graduate medical education and other teaching programs appropriate to our scope of services. Provide contemporary facilities and technology that support high quality health care.
7. DEVELOPS RETROSPECTIVE AND PROSPECTIVE STUDIES TO DETERMINE AREAS WHERE THE INFECTION RATE COULD BE LOWERED: Monitors specific established criteria to determine procedure compliance as needed, or requested.
8. DEVELOPS, REVIEWS, AND REVISES INFECTION CONTROL POLICIES AT LEAST EVERY THREE YEARS. PRESENTS IN-SERVICE PROGRAMS RELATINGTO INFECTION PREVENTION AND CONTROL FOR NURSING AND ANCILLARY DEPARTMENTS: Provides infection control general orientation, nursing orientation held monthly and new resident orientation held annually. Provides in-service education as required and/or requested by an individual or a department.
9. FOLLOWS THE HOSPITAL EXPOSURE CONTROL PLANS/BLOODBORNE AND AIRBORNE PATHOGENS: Demonstrates knowledge of techniques, procedures, and correct use of protective barrier equipment. Expects the same of other team members. Ensures a safe environment by instituting appropriate control measures.
10. IDENTIFIES THE MOST IMPORTANT ASPECTS OF CARE BY FOCUSING, MONITORING AND EVALUATING HIGH-RISK VOLUME AND PROBLEM-PRONE AREAS AND/OR ACTIVITIES: Monitors areas of high-risk, critical care units/special care nursery, as needed. Monitors areas of high-risk/volume; i.e., peripheral and central IV catheters when indicated. Evaluates and identifies problem-prone areas in order to maintain a high quality of care. Evaluates and identifies activities that may impact quality of care. Monitors knowledge and aspects of care related to standard and transmission-based precautions (bloodborne/airborne).
11. MONITORS ALL POSITIVE MICROBIOLOGY AND SEROLOGY REPORTS FOR POSSIBLE INFECTION IN PATIENTS AND EMPLOYEES IN ACCORDANCE WITH THE RECOMMENDATION OF THE INFECTION CONTROL COMMITTEE: Reviews computer reports and notes all positive culture reports daily. Compiles culture reports for chart review. Reports resistant organisms to patient care areas when private room is needed. Identifies potential risk for exposure to an employee or another patient. Receives information via telephone from the lab and institutes immediate action/reporting in order to provide appropriate infection control measures.
12. MONITORS AND OVERSEES PATIENT ADMISSIONS FOR INCOMING INFORMATION: Reviews computer census report to identify patients with community acquired disease daily. Identifies patients with a communicable disease and prevents exposure to others as needed. Communicates information and insures proper infection control measures are in place when indicated.
13. MONITORS AND OVERSEES PLACEMENT OF INFECTED PATIENTS FOR PREVENTION AND/OR CONTROL OF INFECTION: Observes, as needed, the proper placement of pre/post op patients to prevent exposure to another patient with a draining wound. Monitors multi-resistant pathogens, and others, as required. Monitors patients with respiratory infection (i.e.), TB, as needed.
14. MONITORS ENVIRONMENTAL CLEANLINESS AND COMPLIANCE OF PRECAUTION PROCEDURES: Meets with harm reduction teams on a regular basis and participates in the Environment of Care Rounds. Inspections are conducted upon request or to investigate a potential problem. Communicates with Environmental Services department as needed.
15. MONITORS FOR POTENTIAL CLUSTERS OR OUTBREAK OF SITUATIONS AND UNUSUAL OR RESISTANT MICROBIOLOGICAL ORGANISMS: Identifies risk or potential risk of communicable disease or spread of infection and takes appropriate action as needed. Notifies infection control chair and administration immediately when a problem is identified or questioned. Collaborates with local/state agencies when requested. Participates as an active member of the following committees: IC, Harm Reduction, Patient Safety and Error Reduction, EOC, Value Analysis, Surgery, ISYS, Emergency Management and others as necessary. The IP supports Harm Reduction Teams (AHS 2015).
16. PERFORMS APPROPRIATE CONTROL MEASURES OR STUDIES WHEN THE SITUATION INDICATES A DANGER TO ANY PATIENT OR PERSONNEL IN ACCORDANCE WITH THE INFECTION CONTROL COMMITTEE: Monitors selected studies to determine factors involving hospital acquired infection trends or increase in acceptable thresholds, as needed. Recommends new products that impact on reducing potential for infection. Monitors specific patient charts upon the request of local and state DPH.
17. PERFORMS QUALITATIVE REVIEW OF PATIENT RECORDS FOR HEALTHCARE ASSOCIATE INFECTIONS: Review is ongoing during patient admission to determine health care associated infections. Reviews chart after patient discharge in medical records to determine hospital-acquired infections.
18. PROMOTES EFFECTIVE WORKING RELATIONS AND WORKS EFFECTIVELY AS PART OF A DEPARTMENT/UNIT TEAM INTER AND INTRA-DEPARTMENTALLY TO FACILITATE THE DEPARTMENT'S/UNIT'S ABILITY TO MEET ITS GOALS AND OBJECTIVES: Actively participates in department meetings. Supports Alameda Health System’s mission, policies, and procedures through attendance and participation during committee meetings, where applicable. Acts as a professional role model, both clinically and administratively. Effectively and confidentially communicates in all professional situations.
19. PROVIDES INFECTION CONTROL CONSULTANT SERVICE TO OTHER FACILITIES, AND PHYSICIAN OFFICES: Provides resource information both written and verbal upon request. Provides information regarding a patient’s placement and the appropriate precautions to take (i.e., airborne, droplet, contact precautions).
20. REPORTS COMMUNICABLE DISEASES TO THE APPROPRIATE LOCAL AND STATE BOARD OF HEALTH: Reports communicable disease information to local and state DPH in a timely manner. Recognizes diseases involving specific groups; i.e., food handlers that require immediate attention and notification to DPH. Responds according to infection control policy when a patient or employee is diagnosed as having a communicable disease. Serves as a consultant, facilitator and proponent of change in order to provide quality health care and patient safety within the hospitals, rehabilitation center, skilled nursing facility, and out-patient clinics and services.
21. UNDER THE GUIDANCE OF THE INFECTION CONTROL MANAGER, THE INFECTION PREVENTIONIST IS RESPONSIBLE FOR SURVEILLANCE, PREVENTION, AND CONTROL OF INFECTION. REPORTS ALL FINDING TO THE INFECTION CONTROL MANAGER, CHAIRMAN OF THE INFECTION CONTROL COMMITTEE AND OTHER APPROPRIATE COMMITTESS/STAFF AS DEEMED NECESSARY BY THE IC MANAGER: Maintains an effective surveillance system by monitoring daily patient admissions, lab reports, and multi-departmental continuous quality improvement projects. Identifies and communicates prevention measures regarding infection control issues by presenting new products to the product evaluation and standardization committee that will reduce injury and the transmission of microorganisms. Monitors hospital-acquired and the community acquired infections, the latest standards of care presented by OSHA, the Joint Commission, and DPH, and any trends throughout the facility on an ongoing basis. Participates in reviewing all department infection control policy/procedures in order to ensure a safe work environment for all.
22. UNDER THE SUPERVISION OF THE IC MANAGER, PRESENTS THE BI-MONTHLY REPORT TO INFECTION CONTROL COMMITTEE OF HOSPITAL ACQUIRED INFECTIONS AND DISSEMINATES DATA TO MEDICAL, NURSING, AND OTHER DESIGNATED DEPARTMENTS: Compiles information for hospital-acquired infection surgical report. Reports communicable diseases. Identifies areas that exceed recommended thresholds set by the infection control committee. Assists employee health services with management and follow-up of associate exposure as needed. Identifies trends that show a potential problem may exist. Disseminates data to medical and nursing staff in a timely manner.
Education: Possession of a Master's Degree in biological science or Public Health from an approved college or university with specialization in bacteriology, microbiology, epidemiology, or related field; or Valid license to practice as a Registered Nurse in the State of California. For LTC: RN or LVN with two years LTC experience and infection surveillance in a LTC facility will substitute for master degree.
Minimum Experience: Three years clinical health care experience in an acute care hospital preferred. Working knowledge of statistics, microbiology, patient care practices, epidemiology, and occupational health preferred. Two years full-time experience as an Infection Preventionist at an acute care hospital preferred. For LTC: two years experience in LTC preferred.
Required Licenses/Certifications: Obtain Certification in Infection Control (CIC) from Board of Infection Control and Epidemiology within 36 months of hire if not possessed. RN license if a nurse. For LTC Infection Prevention and control certification by NADONA within 6 months of employment is required.