JOB SUMMARY
At Houston Methodist, the Manager Infection Prevention and Control position is responsible for providing leadership and coordination of infection prevention initiatives and fostering a culture of continuous improvement through implementation of evidence-based practices to ensure safety, prevent infections, achieve clinical outcomes and maintain accreditation/regulatory requirements. Duties include disseminating outcomes to leadership, medical staff service line and quality committees; and collaborating with leadership and medical staff to facilitate service line, departmental and unit based reporting and performance improvement efforts focused on infection prevention.

The manager position responsibilities include managing the daily work activities of the work unit/department staff, ensuring quality, productivity, functional excellence and efficiency while assisting management in accomplishing strategic and operational objectives. In addition, this position provides guidance to staff and is responsible for staffing, budget compliance, contributing to staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and assisting in the development and implementation of policies and procedures to ensure a safe and effective work environment. This position also implements training, monitoring and operations initiatives that assure compliance with ethical and legal business practices and accreditation/regulatory/ government regulations.

Requirements:

PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE – 30%

Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the Quality, Patient Safety and Performance Improvement department. Provides development and mentoring of staff. Meets or exceeds threshold goal for department turnover. Develops direct reports to perform these same functions. (EF)
Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. (EF)
Facilitates the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. (EF)
Meets or exceeds threshold goal for department and/or system metrics on employee engagement indicators: action readiness score, tier level. (EF)
Develops and conducts formal training programs for the hospital and the department covering a variety of areas associated with staff safety, infection prevention and control and new programs/initiatives or regulations. (EF)

SERVICE – 20%
Plans and organizes day-to-day Infection Prevention and Control and Quality department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. (EF)
Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for Infection Prevention and Control. (EF)
Serves as a consultant and internal expert for infection prevention and control rules, standards and practices. (EF)
Serves as the hospital liaison to the county, state and external agencies relative to infection prevention and control issues. Coordinates requirements and regulatory requests for state and federal compliance audits. Mentors, coordinates, supervises and evaluates the work of all staff associated with external reporting functions. Ensures that quality data submissions for regulatory agency deadlines are completed in a timely and accurate manner. Works with HIM personnel to ensure all required medical record documentation is submitted for external validation within allowable timeframes. (EF)

QUALITY/SAFETY – 30%
Ensures a safe and effective working environment; monitors and/or revises the Performance Improvement department safety plan and/or any specific accreditation/ regulatory required safety guidelines. (EF)
Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions. (EF)
Employs a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, and identifying solutions via collaboration. Adopts lean principles in driving process improvements. Role models situational awareness, using teachable moments to improve safety. (EF)
Monitors self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance (i.e., focal point review requirements, disaster plan, inservices, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). (EF)
Develops, implements and monitors Infection and Control Program based on evidence based care, applicable laws, regulations, best practices and ensures the hospital’s compliance with accreditation agencies, federal, state and local requirements. (EF)
Evaluates risk of transmission of infectious agents and implements improvement initiatives to provide a safe environment for patients. Performs structured surveillance for monitored healthcare associated infections using nationally established standards and evaluates incidents, trends and threshold data on other infections as needed. Works with the infection prevention team, employee health department, and others to conduct cluster and outbreak investigations, treatments, and immunization programs; institutes control measures as appropriate. (EF)
Develops the annual infection control program, risk assessment and PI plan and leads programs to decrease or eliminate hospital-acquired infections. (EF)

FINANCE – 10%
Assists in the development of department budget and ensures that the department operates in a cost effective manner. Manages/audits department expenses within approved budget parameters, ensuring that the Performance Improvement department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis. Develops staffing plans and schedules to meet department needs that reflect understanding of the importance of cost-effectiveness. (EF)
Implements department strategies to achieve financial target and staffing needs, developing others to do the same, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. (EF)

GROWTH/INNOVATION – 10%
Identifies and implements innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed activities. Supports change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. (EF)
Proactively evaluates processes; recommends and implements action plan(s) for change. Participates in the development and implementation of new procedures and the review and revision of existing procedures. (EF)
Identifies opportunities and takes action to build strategic relationships between one’s area and other areas, teams, departments, and units to achieve business goals. (EF)
Seeks opportunities to identify developmental needs of self and staff and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the individual development plan (IDP) on an on-going basis. Conducts conversations with staff on their development and IDP. (EF)

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Qualifications:

EDUCATION REQUIREMENTS

Master’s degree in allied health, healthcare administration, business administration or a clinical discipline

EXPERIENCE REQUIREMENTS
Three years of progressively responsible staff experience within hospital quality/ performance improvement/project management/infection prevention
Two years of management experience preferred

CERTIFICATIONS, LICENSES AND REGISTRATIONS REQUIRED

Certification in Infection Control (CIC) from the Certification Board of Infection Control and Epidemiology (CBIC)
Six Sigma certification, Certified Professional in Healthcare Quality (CPHQ), Project Management Professional (PMP) certification, or specialty certification in clinical discipline preferred

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message
Demonstrates the ability to interact with others in a way that gives them confidence in one’s intentions and those of the organization
Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one’s own behavior to accommodate tasks, situations and individuals involved
Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills
Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences
Ability to work effectively in a fast paced environment
Demonstrates flexibility and adaptability in the workplace
Demonstrates experience in understanding and executing performance improvement concepts and activities
Advanced skill in use of spreadsheet and relational database software
Strong presentation skills and ability to facilitate work teams
Skill in use of clinical and operational outcomes and comparative performance benchmark databases

SUPPLEMENTAL REQUIREMENTS
Work Attire: Yes/No
Uniform: No
Scrubs: Yes
Business professional: Yes
On-Call* Yes, on a limited basis (for Exempt jobs only)

*Note that employees may be required to be on-call during emergencies (i.e. Disaster, Severe Weather Event, etc.) regardless of selection above.