Infection Prevention Specialist (RN) - Quality Management

Essential Responsibilities

• Assist in implementing and maintaining the infection prevention and control program in compliance with CDC, TJC, Title 22, OSHA, APIC, CMS, and state regulations.
• Support readiness for regulatory surveys and inspections.
• Follow established policies and procedures for infection prevention practices, including aseptic techniques and exposure control.
• Lead/participate in mock tracers, audits, and readiness rounds; maintain evidence of compliance.
• Act as a resource and subject matter expert, helping ensure alignment with CHOMP’s strategic goals and quality initiatives.

Surveillance & Data Collection

• Perform routine surveillance for HAIs using standardized definitions.
• Collect, validate, and enter infection prevention data into NHSN and other required reporting systems.
• Monitor trends and assist in preparing reports for committees and leadership.

Patient Safety Events, Risk Mitigation & Learning

• Partner with Risk Management to review patient safety events, near misses, and grievances; perform targeted chart reviews and case tracers.
• Facilitate or contribute to RCA/After-Action Reviews; develop corrective action plans (CAPs) and monitor effectiveness and sustainment.
• Lead proactive hazard surveillance and failure mode identification; embed feedback loops (huddles, visual controls, standard work audits).

Performance Improvement & Education

• Facilitate Lean Model for Improvement projects (AIM, driver diagram, PDSA cycles) at the unit and service line level.
• Coach leaders, charge nurses, educators, and physicians on measure definitions, documentation, and bundle reliability tactics.
• Design and deliver adult-learning education (tip sheets, micro-learning, in-services) based on identified performance gaps.

Committee & Workgroup Facilitation; Stakeholder Engagement

• Lead or co-lead relevant committees/work groups (e.g., Infection Prevention Work Group, Unit-based councils, etc.).
• Prepare agendas, minutes, dashboards, and storyboards; track actions to closure and communicate progress.
• Maintain strong relationships with Nursing, Medical Staff, Case Management, Infection Prevention, Pharmacy, Lab, Radiology, and IT/Analytics.
• Provide supported groups with reliable data, coaching, and process improvement support.