Job Description
The Manager, ASC Infection Control and Quality Management is responsible for developing, implementing, and evaluating the Infection Control Program, Quality Assurance and Performance Improvement Programs (including QAPI Studies) for all Springfield Clinic Ambulatory Surgery Center Service Lines at multiple locations, so as to protect patients, staff, and visitors.

Job Relationships
Reports to the Director of Operations

Principal Responsibilities

Responsible for the successful implementation, execution, and completion of Infection Control and QAPI programs, as well as the temporary supervision of personnel involved with implementation, oversight, and reporting of special projects.

Collaborate with ASC leadership on periodic required reviews, provide input on annual colleague evaluations, and assist with creating annual performance goals; ensure colleague accountability and solutions for employee performance problems, when requested.
Promote a positive, team-oriented and productive work environment.
Assume role of staff personnel when needed.

Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
Prepare reports for committees, accrediting bodies and mandatory questionnaires.
Comply with regulatory and accrediting agencies such as AORN, APIC, CDC, OSHA, and CMS.
Work on a routine basis with the Quality Management and Clinical Development Departments.
Obtain and manage data and information collected, in an organized and presentable manner.

Proactively and willingly seeks out educational opportunities for personal and professional growth.
Perform other job duties as assigned.

Infection Control Responsibilities
Provide infection control education to all staff.
Oversee infection control surveillance of all staff and physicians, promoting good practices.
Develop and recommend infection prevention and control policies and procedures.
Assist in identifying infection risks of new products and procedures.

Maintain and update Infection Control Plan and Manual.
Serve as a consultant on matters relating to Clinic infection prevention and control, Quality Management, and Staff Education.

Identify and conduct community (external) and Clinic (internal) assessments of high-risk areas related to acquiring and transmitting infections among patients, employees, physicians, vendors, other practitioners, volunteers, students, and visitors.

Quality Management Responsibilities

Compile and report data on ASC surgical site infections, unanticipated events, and other variances.
Comply with the Springfield Clinic incident reporting policy and procedure.
Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
Direct the enrollment and summation of benchmark studies.

Maintain and update Quality Assurance and Performance Improvement (QAPI) Plan

Participates in Root Case Analyses (RCAs) and other data collection and analysis activities at the request of Director of Operations, Quality Management Department, or Clinic Administration.

Reports fully-vetted and clinically-supported data in a professional manner to the appropriate bodies.

Staff Education Responsibilities

Coordinates vendors for equipment in-services prior to equipment being used clinically and as needed for refresher training.

Coordinates code drills, evaluates drills, and offers staff education on best practices and with Springfield Clinic resources.

Responsible for emergency preparedness training of staff, conducting drills and evaluating drill performance of staff.
Conducts, coordinates, and documents training to ensure constant and consistent implementation of approved infection control practices, QAPI plan, and other approved Clinic education initiatives.

Utilizes Infection Control and QM data as opportunities to create educational opportunities for staff and physicians.

Education/Experience

Minimum of 2 years of experience in a health-related field such as Infection Control or Public Health required

Minimum of 2 years of nursing experience in a surgical setting (pre-operative, OR Post-operative) required
Previous clinical and/or management experience in Infection Control preferred
Bachelors or Master's degree in Nursing preferred.

Licenses/Certificates
Current Illinois RN license required.

Certification in Infection Prevention and Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC) within one year.

Must maintain Association for Professionals in Infection Control and Epidemiology (APIC) and AORN membership.

Knowledge, Skills and Abilities
Must have the ability to troubleshoot, apply critical thinking and provide viable suggestions for problem resolution.
Must be highly energetic with the ability to develop and implement teaching materials and training programs.
Knowledge of nursing practices and techniques for data collection is required.
Ability to conduct training seminars and exercises is required.
Excellent verbal written, and presentation communication skills and computer and problem solving skills are required.
Familiarity with pertinent requirements for regulatory and advisory bodies is required.

Experience with teaching a diverse group of adult learners, preferred.

Work Environment
Interacts with a variety of people on potentially highly-sensitive and confidential issues.
Must be mobile throughout the department.
Normal office environment with computer and phone use.
Requires walking, sitting, bending, twisting, hearing and standing activities.

Frequent travel required up to 50% of time, within 75-100-mile radius

PHI/Privacy Level
HIPAA1