Quality, Risk, and Infection Manager chez Animas Surgical Hospital, LLC

Job Summary:

The Quality, Risk, and Infection Prevention Manager is responsible for developing, implementing, and maintaining comprehensive quality monitoring and reporting, risk management, and infection prevention strategies across the organization. This position ensures compliance with regulatory standards and industry best practices, promotes a culture of safety, and provides leadership and direction to effectively manage and mitigate organizational risks.

Reports to: Director, Quality

Salary range (Exempt): $70,000 to 145,000 (salary range is intentionally broad as pay will be determined based on qualifications, experience and eligibility for bonuses)

Essential Job Functions:

• Quality Management

1. • Analyze performance data and assigned quality measures. Identify trends, gaps, and opportunities and evaluate the need for quality improvement initiatives, policies, and procedures in line with regulatory requirements and organizational goals.
   • Collaborate with cross-functional teams to implement process improvements that enhance patient care, operational efficiency, and service quality.
   • Lead and facilitate quality committees or workgroups, ensuring consistent application of quality standards throughout the organization.

• Risk Management

1. • Monitor and evaluate the enterprise-wide risk management program in partnership with the Quality Director to identify organizational risk.

1. • • Analyze incident reports and partner with hospital leadership for timely follow up and closure of events.
     • Monitor for trends in events related to processes and individuals for potential quality improvement initiatives.
     • Investigate adverse events to determine root causes and develop corrective action plans.

1. • Educate staff on risk prevention strategies, regulatory requirements, and best practices to promote a proactive culture of safety.
   • Review patient complaints and evaluate the need to escalate to a grievance according to CMS definitions.

1. • • Draft and respond to identified grievances according to hospital policy.
     • Facilitate the review of grievances at the assigned hospital committee.

1. • Coordinate with legal, claims and insurance regarding high-risk events.

• Infection Prevention & Control

1. • Establish, implement, and monitor infection prevention and control policies and procedures to minimize the spread of infectious diseases.
   • Lead organizational compliance with infection prevention guidelines from relevant agencies (e.g., CDC, WHO, OSHA, The Joint Commission).
   • Conduct regular infection control surveillance, audits, and risk assessments to identify areas for improvement.

1. • • Provide routine follow-up to identified areas for opportunity to ensure compliance with action plans.

1. • Provide guidance and expertise during outbreaks or infection-related emergencies, ensuring appropriate containment and mitigation measures are in place.
   • Partner with departmental leaders to investigate and report hospital acquired conditions (e.g., SSI’s, CAUTI, CLASBSI, Emerging Infections).
   • Submit required data to NHSN and ensure accurate public reporting of healthcare-associated infections.

• Employee Health

1. • In alignment with OSHA and CDC guidance, review and coordinate employee health follow up.
   • Partnering with Clinical Education, Human Resources, and Credentialing as needed.

• Regulatory Compliance & Accreditation Support

1. • Stay current with healthcare regulations, accreditation standards, and applicable laws related to quality, risk, and infection prevention.
   • Collaborate with department leaders to address deficiencies and implement corrective actions promptly.

• Leadership & Collaboration

1. • Partner with clinical and administrative leaders to align departmental initiatives with organizational priorities.
   • Communicate effectively with senior leadership, providing regular updates on performance, risk status, and infection prevention efforts.
   • Collaboration with state and local public health offices.

• Performs other duties as assigned.

Minimum Requirements:

• Education:
  •  Bachelor’s degree in Nursing, Public Health, Healthcare Administration, or a related field required.
  • Master’s degree in Healthcare Administration, Nursing, Public Health, or a related field preferred.
• Experience:
  • Minimum of 3 years of experience in Healthcare Administration, Nursing, Public Health, or a related field.
  • Demonstrated leadership experience, including facilitation of meetings, closed loop communication and follow-up, and program development.

Certification, Licensure:  Current state license as a registered nurse; current CPR certification; ACLS, PALS or TNCC certifications per policy.

Location: This position is located on site and is not eligible for remote work.

Experience, Training, Knowledge

• • Knowledge of healthcare regulations, accreditation standards (e.g., Joint Commission), and guidelines (e.g., CDC, OSHA).
  • Strong analytical and problem-solving skills with a proven ability to interpret data and metrics.
  • Excellent communication, presentation, and interpersonal skills to effectively engage various stakeholders.
  • Ability to manage multiple priorities, work under pressure, and adapt to a rapidly changing environment.
  • Proficiency in Microsoft Office Suite and data analysis tools.

Physical Requirements:

• Primarily an on-site, office-based position, with regular interaction throughout clinical and administrative areas.
• Occasional travel between sites may be required.
• Must be able to perform essential functions safely and successfully, with or without reasonable accommodation.             

Working Conditions/Environmental Exposures:

Environmental hazards such as chemicals, solvents, needles, needle containers, sharps, blood, body fluids, various infectious/communicable diseases, infectious medical waste, radiation, and/or radioactive materials and/or radioactive waste, proximity to moving mechanical parts. Protective clothing/equipment may be necessary.

Animas Surgical Hospital offers a competitive benefits package including but not limited to health, dental, vision, & life insurance. 401k with employer matching

Animas Surgical Hospital is a drug free workplace and performs a pre-employment drug screen which includes marijuana.

ASH IMMUNIZATIONS AND VACCINATIONS REQUIREMENTS – Aligns with CDC’s Advisory Committee on Immunization Practices (ACIP) for Healthcare Personnel 

• Hepatitis B- Lab evidence of immunity (titer) to Hepatitis B or three doses Hep B vaccine at appropriate intervals
• Influenza- documentation of current seasonal flu vaccine (mandatory from November 1st through March 31st each year)
• Measles, Mumps, and Rubella - Lab evidence of immunity (titer) to Measles, Mumps, and Rubella or 2 doses of MMR Vaccination
• Varicella (chickenpox) - Lab evidence of immunity (titer) to Varicella or 2 doses of Varicella Vaccine
• Tetanus, diphtheria, pertussis (Tdap) - documented proof of immunization
• Tuberculosis Screening - Documentation of a two-step TB skin test within the past year OR lab verification of a negative TB Gold or T-Spot tuberculin test within the past 6 months

* VACCINE RECORDS OR EVIDENCE OF IMMUNITY ARE REQUIRED PRIOR TO 1ST DAY OF SCHEDULED WORK