Ensures clinical practice and ambulatory surgery center safety and risk prevention by the creation of regulatory compliant policies and procedures, performing risk assessments, and ongoing monitoring of the facility and its staff.
Evaluates quality of care and patient outcomes related to infection prevention and control; collects and reports information to the QAPI committee as it relates to infections and infection prevention, monitors employee program compliance, maintains program and documentation for compliance with Infection Prevention/Control monitoring, recording, and reporting requirements. This role requires a very high degree of independent work and judgment with the authority to make independent decisions on matters that may affect the business or significant parts of the business.
Essential Duties and Responsibilities:
Meets and supports the organizations core values, standards, and customer service standards including interpersonal communication and professional conduct expectations
Assists with general and specialized training to colleagues relating to Risk Management, patient relations, Infection prevention, and customer relation topics to employees
Identifies needs and provides opportunities for staff to acquire and maintain knowledge through informal training and development programs geared towards Risk Management, Infection prevention, and patient relations topics.
Incorporates regulatory guidelines and standards in Risk Management, Infection prevention, and QAPI program development
Assists with policy creation and adaptation as needed
Assists teams with compliance of regulatory standards and requirements and facilities CMS compliance
Provides ongoing assistance to employees with incident reporting
Prepares reports to the Governing Board regarding Risk Management and effectively communicates suggested improvements, possible risks, and adverse events
Proactive analysis of patient safety and medical error processes
Participates in the process of disclosure for medical errors
Participates in root cause analysis investigation and reporting adverse drug events and sentinel events to the appropriate parties
Maintains awareness of legislative and regulatory activities related to healthcare risk management.
Complies with various codes, laws, rules, and regulations concerning patient care, including those mandated by state and federal agencies, incident reporting. Includes investigation activities of federal, state, and local enforcement authorities
Provides in-service training to medical center personnel to enhance their awareness of their role in reducing liability exposures
Maintains a risk management education calendar
Takes steps to ascertain that risks are minimized through follow-up and actions on all regulatory/insurance survey report recommendations/deficiencies
Receives and investigates reports of product problems to determine appropriate response (in-house recalls, independent evaluations, etc)
Participates on select committees, conferences, and QAPI activities related to provision of patient care
Receives incident reports and other information regarding untoward occurrences in the facility, such as quality assurance outliers or variations, and collates such information systematically to permit analysis pursuant to risk management policy and procedure.
Reviews collated data to identify trends regarding accidents or occurrences, and recommends corrective action to management, if appropriate
Plans, organizes, and executes compliance programs in areas of employment, housing, and education under authority of federal, state, or local discriminatory legislation.
Establishes and coordinates activities of local community relations committees.
Conducts investigations to resolve complaints and report violations for adjudication.
Plans informational programs to stimulate and maintain community interest and support.
Cooperates with local, state, and federal governmental units and other organizations in identifying needs and providing assistance in enforcement of statutes.
Contributes to the development and progression of the approved QAPI program
Initiates plans to achieve full staff development as it relates to infection prevention
Objectively evaluates suggestions, grievances, and processes to identify opportunities to improve performance of Infection prevention program and quality of care
Documents information related to infection prevention/control and ensures information is disseminated to the appropriate people or departments
Researches and submits pertinent articles for physicians and staff to review
Seeks new learning experiences to enhance infection prevention knowledge and support assigned responsibilities
Maintains membership in relevant professional organizations
Schedules and plans Infection prevention/control committee meetings, staff in-services, seminars, and conferences according to job responsibilities and facility requirements
Organizes and participates in orientation of staff to development programs which meet identified learning needs related to Infection prevention/control
Reports observed or suspected violations, hazards, and noncompliance to the Medical Director, Human Resources and COO/CFO
Responds to emergency situations with competence and composure
Establishes a comprehensive Infection Prevention/Control training program for employees
Reviews Infection Prevention/Control and health principles, standards, laws, rules, and regulations. Ensures the facility and IP program benefits from acquired knowledge
Recommends actions to achieve compliance with requirements for the outpatient health care setting
Participates in the development of IP related facility policies and procedures
Participates in IP-related orientation programs for new employees
Participates in the development of IP-related continuing education programs for employees
Directs and participates in IP surveillance and incident reporting on a regular basis. Audits employee activity for compliance with IP- related policies and procedures
Investigates with Risk Manager designee all incidents that involve infection potential infections or outbreaks and submits reports to QAPI committee, state agencies, and accreditation organizations as required by law or regulation
Develops a method of continual review and assessment of the IP plan with the Risk Manager Designee that includes: analyzing employee compliance deficiencies, recommends policy and procedure revision and training measures; prepares reports and plan analyses for presentation to the QAPI committee; implements changes as directed by the QAPI committee; maintains adequate supplies and availability of personal protective equipment (PPE), engineering and workplace controls with particular regard to hand hygiene; reviews locations and use of personal protective equipment (PPE) with employees.
The above cited duties and responsibilities describe the general nature and level of work performed by people assigned to the job. They are not intended to be an all-inclusive list of the duties and responsibilities that an incumbent may be expected or asked to perform.
Four to ten years related experience and/or training; or equivalent combination of education and experience.
Must hold current Registered Nurse License
Training/experience in Infection Prevention/Control with appropriate background in healthcare and related sciences
Certificate in Infection prevention
CNOR certification is preferred. CNOR certification is the gold standard. It is “documented validation of the professional achievement of identified standards of practice by an individual registered nurse providing care for patients before, during and after surgery.”
Internal Number: 101
About Ponte Vedra Plastic Surgery
At Ponte Vedra Plastic Surgery, we strive for excellence in the care we provide and in the results that we achieve. Offering numerous cosmetic and reconstructive surgeries, along with nonsurgical procedures at multiple locations, our board-certified plastic surgeons and staff are able to provide superior results. Since we truly value each patient, we attend ongoing training to provide the most advanced procedures in our state-of-the-art facilities. In addition, our main location features a fully licensed and accredited ambulatory surgery center. Our ultimate goal is to provide Northeast Florida with world-class surgery in a safe and welcoming environment.