Quality & Infection Control RN

Infection Prevention and Quality Manager Summary

The Infection Prevention RN is a registered nurse, qualified with knowledge of CDC, APIC, and

AORN guidelines and definitions of healthcare associated infections (HAIs), federal and state

regulations. The individual is responsible for the identification, investigation, reporting, prevention

and control of healthcare associated infections (HAIs) among patients and personnel. The

individual may institute collection of cultures and initiate appropriate isolation precautions. The

individual is responsible for assisting with in-service programs related to infection prevention and

control.

Essential Functions

• Demonstrates comprehensive knowledge of the infection prevention process in a

healthcare setting.

• Demonstrates understanding of standard and isolation precautions as set forth by the CDC,

APIC, AORN, and LA State Board.

• Attends continuing education programs and maintains current knowledge of all aspects of

infection prevention.

• Demonstrates knowledge of microbiology, and modes of transmission of disease entities.

• Demonstrates ability to teach principles and practical application of infection prevention

to all levels of healthcare personnel.

• Demonstrates ability to develop infection prevention policies and procedures.

• Develops and implements a system for identifying, investigating, reporting and preventing

the spread of healthcare-associated infections (HAIs) among patients of all ages and

healthcare personnel.

• Confers with staff nurses on all patient care units on a regular basis to determine occurrence

of healthcare-associated infections (HAIs).

• Confers with medical and nursing staff to determine appropriate implementation of

isolation precautions.

• Investigates all in-house infections and/or infections that occur within 30 days of surgery.

• Initiates culture and sensitivity and/or appropriate isolation precautions when indicated.

• Communicates appropriate reports to Quality Assurance Performance Improvement

(QAPI) Committee quarterly.

• Completes required reports of CDC in a timely and accurate manner.

• Maintains accurate records of healthcare-associated infections (HAIs) among patients and

personnel.

• Assists in the development, implementation and improvement of infection prevention

practices.Page 2 of 3 Rev. 03/2023

• Communicates infection prevention activities to Administration and the Quality Assurance

Performance Improvement (QAPI) Committee quarterly.

• Prepares statistics and other pertinent data and reports at least quarterly.

• Implements and conducts special studies when appropriate or requested by physicians or

administration.

• Reviews the Infection Prevention policy and procedure manual at least every two (2) years

and ensures compliance with the CDC, APIC, AORN, and LA State Board.

• Based on studies which identify areas for improved patient outcomes, submits targeted

surveillance indicators approval on an annual basis.

• Available to assist all departments regarding issues related to infection control.

• Stays abreast of changing infection prevention practices and implements new methods to

improve the efficacy and outcomes of the Infection Prevention Program.

• Assists with in-service education related to infection prevention hospital-wide.

• Performs other duties as assigned.

Physical Demands

While performing the duties of this job, the employee is regularly required to sit; stand, walk; use

hands to finger, handle or feel; and reach with hands and arms. The employee is occasionally

required to stand; walk and stoop, kneel, crouch, or crawl. The employee must frequently lift

and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision

abilities required by this job include close vision, distance vision, color vision, peripheral vision,

depth perception and ability to adjust focus.

Required Education and Experience

• Graduate of an accredited school of nursing.

• Knowledge of CDC, APIC and AORN guidelines.

• Knowledge of healthcare-associated infections (HAIs).

• Knowledge of Federal and State infection prevention regulations.

Required Skills and Certifications

• Current Louisiana Registered Nurse Licensure.

• APIC training course or equivalent required.

• APIC Membership required.

EEO Statement

Our corporation is committed to equal employment opportunity. We do not discriminate against

employees or applicants for employment on any legally-recognized basis ("protected class")

including, but not limited to: race, color, religion, national origin, sex, pregnancy (including

childbirth and related medical conditions), age, disability, citizenship status, status as a current or

former uniformed servicemember, genetic information, or any other protected class under

federal, state, or local law.

Quality Manager Summary

The Quality Manager shall promote and support the Quality Assurance Performance Improvement

(QAPI) program and be responsible for developing and establishing quality procedures, standards

and specifications for the hospital.

Essential Functions

• Ensures that processes needed for the Quality Management System (QMS) are established,

implemented and maintained.

• Reports to top management on the performance of the QMS and any need for improvement

via management review.

• Acts as a liaison with the accreditation body on all matters related to the external

accreditation process.

• Ensures that a document control procedure is adopted to approve, review and update all

changes to critical documents within the scope of the QMS.

• Ensures that records are established and maintained to provide evidence that the QMS is

being followed and that there is a system in place for the identification, storage, protection,

retrieval, retention time and disposition of such records.

• Ensures that the performance of the QMS is reviewed at planned intervals to ensure its

continuing suitability, adequacy and effectiveness.

• Ensures that Quality Objectives are set by top management for measuring the performance

of the QMS and that these are regularly reviewed.

• Ensures that all suppliers used by the organization are selected, evaluated and re-evaluated

and that records of this assessment are maintained.

• Ensures that an internal audit program is adopted to verify that the QMS conforms to

policies and procedures and is effectively implemented and maintained; takes appropriate

action when this is not the case.

• Analyzes data on the effectiveness of the QMS and evaluates where continual

improvements of the QMS can be made.

• Coordinates continual improvement of the QMS, ensuring that evidence of corrective and

preventative actions taken are recorded and reviewed.

• Performs all aspects of Quality Management according to the hospital's Quality

Management Policy and the Quality Manager's job description.

• Ensures that there are appropriate processes throughout the hospital to effectively

communicate the hospital's Quality Policy.

• Promotes Quality Management awareness throughout the hospital and provides education

as needed.Page 2 of 2 Rev. 03/2023

• Participates as an active member on at least one hospital committee that improves overall

quality.

• Performs other duties as assigned.

Physical Demands

While performing the duties of this job, the employee is regularly required to talk or hear. The

employee is frequently required to stand; walk; use hands to finger, handle or feel; and reach with

hands and arms.

Required Education and Experience

• Knowledge of ISO 9001.

Required Skills and Certifications

• Completed ISO 9001 or equivalent training.

• Knowledge of Microsoft office suite.

• Detail-oriented and strong multi-tasker.

• Exceptional communication skills.

EEO Statement

Our corporation is committed to equal employment opportunity. We do not discriminate against

employees or applicants for employment on any legally-recognized basis ("protected class")

including, but not limited to: race, color, religion, national origin, sex, pregnancy (including

childbirth and related medical conditions), age, disability, citizenship status, status as a current or

former uniformed servicemember, genetic information, or any other protected class under

federal, state, or local law.