Quality Risk/ Infection Control Manager

Essential Functions

Program Development & Oversight

• Develops, implements, and annually evaluates the hospital’s Infection Prevention and Control Plan in alignment with facility goals, risk assessments, and TJC/CMS standards.
• Establishes and maintains policies and procedures for infection prevention and employee health related to communicable diseases and exposures.
• Conducts an annual infection control risk assessment based on population served, services provided, and environmental risks.

Surveillance and Data Reporting

• Conducts ongoing infection surveillance and monitors trends in healthcare-associated infections (HAIs) and communicable diseases across all hospital departments.
• Collects, analyzes, and reports infection data to leadership, the Quality Assurance Committee, and regulatory agencies as required.
• Investigates outbreaks and clusters of infection, determines sources, and implements corrective actions.
• Submits required reports to local and state health departments and participates in national or state reporting systems as applicable.

Education and Staff Training

• Develops and conducts initial and ongoing staff education on infection prevention and control, including hand hygiene, standard and transmission-based precautions, personal protective equipment (PPE), environmental cleaning, and bloodborne pathogen exposure prevention.
• Provides real-time coaching and feedback to staff during environmental rounds and infection control observations.
• Ensures annual competency validation related to infection prevention practices.

Performance Improvement

• Collaborates with the Quality and Safety Committee to identify infection prevention performance measures and improvement projects.
• Utilizes data-driven methods and evidence-based practices to develop and monitor Performance Improvement Plans (PIPs) targeting infection prevention outcomes.
• Participating in root cause analyses and sentinel event reviews related to infection control issues.

Occupational Health & Immunizations

• Monitors staff immunization compliance and exposure management (e.g., influenza, Hepatitis B, tuberculosis testing).
• Oversees influenza vaccination program for employees, volunteers, trainees, and contract personnel with patient contact, maintaining documentation and compliance reports.
• Ensures appropriate follow-up and documentation for staff exposure incidents (e.g., bloodborne pathogens, airborne exposures).

Environmental Rounds and Risk Management

• Conducts regular infection prevention rounds in clinical and non-clinical areas, ensuring compliance with hand hygiene, isolation procedures, environmental cleaning, and equipment disinfection.
• Partners with Environmental Services and Facilities to address environmental infection control issues, including construction/renovation risk assessments and water management.
• Ensures the implementation of interim life safety and infection prevention measures during construction and renovation projects.

Regulatory Compliance

• Maintains a thorough understanding of Joint Commission IC standards, CMS infection control regulations, and applicable state health department requirements.
• Prepares and maintains documentation for regulatory and accreditation surveys.
• Serves as a content expert and liaison during TJC, CMS, and state health department inspections.

Committee Participation

• Provides routine reports to the Quality and Patient Safety Committee.
• Collaborates with medical staff, nursing leadership, and other departments to ensure infection prevention integration across all hospital functions.

Minimum Qualifications

Education:

• Minimum: Associate Degree in Nursing (ADN)
• Preferred: Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing, Public Health, or related field

Experience:

• Minimum of three (3) years of experience as a Registered Nurse in an acute or behavioral healthcare setting.
• At least two (2) years of experience in infection prevention, employee health, or quality improvement preferred.
• Knowledge of surveillance systems, microbiology, epidemiology, and infection prevention practices required.

Licensure / Certification:

• Current and unrestricted RN license in the state of practice.
• Basic Life Support (BLS) certification required.
• Infection Control Certification through American Health Training is required
• Certification in Infection Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC) preferred
• CPI (Crisis Prevention Intervention) certification within 90 days of hire.

Additional Requirements

• Demonstrates working knowledge of Infection Control Standards (TJC IC Chapter) and CMS Condition of Participation §482.42 (Infection Control Program).
• Maintains confidentiality and compliance with HIPAA and hospital policies.
• Participates in emergency preparedness and pandemic response activities.
• Assists with floor nursing as assigned, within scope of infection control responsibilities.
• Participates in hospital-wide committees as assigned.

Employee Acknowledgment
I have reviewed and received a copy of the Infection Control Nurse Job Description. I understand this description outlines general duties and that additional related duties may be assigned as necessary for the hospital’s operation and compliance.