The Manager of Quality, Safety & Infection Prevention (MQSIP), in collaboration with the Director of Quality, Compliance, Risk and Safety (DOQ), is responsible for providing “on the ground” support and expertise to achieve the goals of the Performance Improvement & Quality and Safety Plan of Asheville Specialty Hospital (ASH) by: tracking, analyzing and monitoring hospital performance measures, deploying quality methods and tools, closing performance gaps, providing staff education, coaching and mentoring staff to successfully implement evidence-based practices, following up and coordinating action plans, and fostering teamwork.
This position also serves as the Infection Prevention (IP) specialist for ASH with responsibilities such as: developing and managing the Infection Control Plan, retaining responsibility for IP associated hospital policies, promoting an environment of proactive IP, proactive surveillance strategies, hands on involvement in quality activities involving IP, coaching on prevention and control strategies, and implementing evidenced based infection control practices and policies. The MQSIP also investigates suspected or known sources of infection. The MQSIP utilizes the ASH RCA process to identify deep causal factors, implement improvements, and monitor action plan gains.
The MQSIP stays abreast, evaluates, communicates to leadership and staff, and implements the Joint Commission, NHSN, CDC, and CMS Patient Safety regulatory standards and recommendations for IP as appropriate for the LTACH patient population. This position is responsible for being a positive role model for quality, safety, and IP principles and facilitates the use of clinical and process measures to drive decision making.
The Manager of Quality, Safety and Infection Prevention is responsible for day to day IP duties and other activities as delegated by the Director of Quality, Compliance, Risk and Safety.
Quality, and Regulatory Compliance
Acutely familiar with Long Term Acute Care Hospital Quality Reporting Program (LTCH QRP) Care Data Set admission and discharge assessments and able to serve in a back-up role to DOQ as assigned.
Serves as an expert in the NHSN, CDC, LTCH CMS Conditions of Participation (CoPs), Joint Commission Standards and other applicable regulatory requirements and ensures IP associated measures are met.
Ensures continuous survey readiness in the area of IP.
Proactively stays informed of changes in regulatory standards and educates leadership and staff in order to make timely quality, safety, and IP process changes and communicate those anticipated changes to leadership.
Ensures the monitoring, tracking, and reporting of essential IP quality measures for required and strategic performance indicators.
Works closely with the DOQ to ensure Quality and Safety Program is addressing appropriate content, has involvement at all levels of the organization, and outcomes are well communicated.
Ensures analysis of IP, Quality, and Safety data and collaborates with DOQ to ensure interpretation of findings is accurate.
Assists in ensuring processes are in place to maintain hospital licensure, accreditation, and regulatory compliance.
Provides support for mock surveys to ensure well-coordinated pre-survey, onsite survey, and post survey activities (e.g., timely application submission documentation preparation, survey planning, improvement plan, and compliance tracking).
Effectively conducts infection control surveys of hospital departments.
Participates in antimicrobial stewardship program efforts by assisting with prompt detection of multidrug-resistant organisms, promoting compliance with standard and transmission-based precautions, incorporating stewardship activities into the annual infection prevention risk assessment, and supporting appropriate antibiotic usage.
Under direction of DOQ, monitors, investigates, and appropriately responds to occurrence reports and patient grievances and reviews complaints about quality of care, including clinical case review.
Prepared for meetings; ensuring data is accurate and reflective of goals and benchmarks.
Continuously strives towards departmental and organizational goals.
Is visible in patient care and departmental areas, partnering with all staff to ensure priorities for improvement are utilizing quality processes and tools.
Ensures policies reflect current practice and that applicable regulatory standards are incorporated.
Proactively assesses exposure risk within hospital departments and takes steps to ensure compliance to policies.
Serves as consultant to leadership; facilitating positive, consistent, and collaborative interactions.
Completes other duties to support departmental operations as assigned or requested.
Assists in the design and deployment of the ASH Safety Program focusing on continuously improving safety outcomes for all patients, visitors, and employees.
Ensures analysis of data related to patient and employee safety events in order to identify trends and opportunities for system and enterprise level process improvement.
In collaboration with the DOQ, ensures investigations of safety events and completion of root cause analysis (RCA); partnering with leadership to identify cross- departmental opportunities for improvement.
Applies proven proactive and reactive methodologies and tools (FMEA, RCA, surveillance, and risk assessments) to identify and evaluate patient safety risks.
Uses science of patient safety to apply process and performance improvement methods and tools to improve patient safety reporting and drive improved patient and process outcomes.
Supports the DOQ to complete regulatory reporting of any required safety events and annual employee injury reporting (OSHA 300).
Ensures a proactive approach to safety risk assessments for employees within their work environments and takes steps to ensure the workplace minimizes opportunities for injury.
Assists in the completion of safety performance measures in order to report to the QSC, MEC, and Governing Board in a timely fashion and provides counsel to groups regarding strategies to improve any performance gaps.
Reviews all employee injuries to identify trends and drive action planning and collaborates with Workers Compensation Provider to ensure compliance with plan.
Participates in orientation of new staff concerning quality, safety, and IP expectations at ASH.
Responsible for educating staff to new products, new information, practice changes or other areas of content expertise of this role as it arises throughout the year.
Responsible for collaborating with the Clinical Development Coordinator to ensure annual Learning Management Modules (LMS) accurately reflects required quality, safety, and IP content.
Collaborates with leaders, committees, and hospital Clinical Development Coordinator to ensure all staff are educated regarding ASH’s quality methods and tools.
Facilitates workshops as delegated using appropriate methods affirmed through the Quality and Safety Committee.
The employee effectively communicates appropriate and thorough information, in a professional and respectful manner, to all customers and teammates in accordance with ASH Core Values.
Teamwork The employee is an effective team member by supporting inter-disciplinary collaboration and readily assisting co-workers. The employee displays ASH Core Values by performing duties within their scope of practice, as assigned.
Customer Service and Accountability The employee demonstrates a positive attitude and willingness to assist customers and team members to meet or exceed all expectations of care. The employee embraces diversity within the work environment and consistently interacts with all customers and team members in a friendly and respectful manner.
Professional Conduct and Work Ethics The employee exhibits a positive attitude in support of the organization and leadership. The employee treats hospital resources and property with respect and in a manner that reflects awareness of financial responsibility. The employee adheres to all policies and procedures related to safety, infection control, and corporate compliance.
Minimum Qualifications and Requirements
EDUCATION: Bachelor of Science in Nursing and Master’s Degree in Nursing, Public Health, Healthcare Administration or a related/applicable field or must acquire Master's degree within three years of employment.
CERTIFICATIONS: Certified Professional in Healthcare Quality (CPHQ) or must acquire within 12 months; Certificate of Infection Control (CIC) or must acquire within 24 months. Current basic life support (BLS/CPR) certification: Red Cross or American Heart Association; Current ACLS or acquire within 6 months.
EXPERIENCE:Minimum of 3 years’ experience in Critical Care, 3 years’ experience in Healthcare Quality and Safety leadership role with experience in Long Term Acute Care (LTCH).
Preferred Skills, Knowledge and Abilities
EXPERIENCE: 5 years experience in healthcare administrative quality leadership role, 5 years experience in LTCH. Familiarity with accrediting standards, including TJC and CMS. Previous experience in Infection Prevention and Control Practices.
SKILLS: Proficient with Excel, PowerPoint, Word, Outlook, and Cerner; Experience with LTRAX and LTCH-QRP; Software used: Truven, Meditech, Compliance-360, RL Solutions, and Paycom.
Work requires standing, walking, sitting, lifting, reaching, stooping, crawling, twisting, pushing, pulling and bending. Must be able to lift up to 50 pounds in equipment and/or supplies. Intact (or corrected) visual acuity, hearing, smell and touch is required. Manual and finger dexterity is required. Must be able to speak and understand English with the ability to communicate effectively. Physical abilities testing may be required.
About Asheville Specialty Hospital-Long Term Acute Care
Long Term Acute Care Hospital
An LTAC offers specialized treatment for each patient over a longer period of time than an acute short-stay hospital. Patients come to us with serious medical problems that require intense, comprehensive treatment for an extended period of time—usually 20 to 30 days. This allows for the patient’s unique needs to be met at the most optimum level and transition to the ...next level of care.
Our approach to care is family-oriented, providing a compassionate atmosphere that improves outcomes and values family as a part of the treatment and recovery process. Our low staff-to-patient ratio allows us to provide intensive, highly-skilled treatment and therapeutic care for a unique adult population.