Infection Prevention Specialist (RN) - Quality Management

Infection Prevention Specialist

Under the direction of the Quality Management Director, the Infection Prevention Specialist supports the facility's infection prevention and control program in compliance with federal, state, and local regulations, as well as organizational policies and standards. This position focuses on surveillance, data analysis, and implementation of evidence-based practices to prevent healthcare-associated infections (HAIs). The Infection Prevention Specialist collaborates with clinical teams and departments to promote patient safety, provides education on infection prevention practices, and assists with regulatory readiness. Acting as a resource and subject matter expert, the role helps ensure alignment with CHOMP's strategic goals and quality initiatives.

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.
• Participate actively during TJC surveys and other regulatory inspections; coordinate corrective actions and sustainment plans.
• Develop, maintain, and educate on policies, procedures, and standard work related to assigned measures and safety practices.
• Provide routine reporting to Administration, Board committees, Medical Staff committees, and quality councils.

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 RCAs/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.

Experience

• Minimum of 3 years recent acute inpatient care experience (ICU, Med-Surg, ED preferred).
• Prior experience in infection prevention strongly preferred.
• Proficiency in Microsoft Office and electronic health record systems (Epic preferred).
• Familiarity with NHSN reporting, APIC guidelines, and regulatory standards.
• Working knowledge of Title 22, TJC standards, CMS Conditions of Participation preferred.

Education

• Bachelor's degree in Nursing (BSN) required or BSN in progress with attainment within 12 months of hire.
• Master's degree in Nursing, Healthcare Administration, Public Health, or related field preferred.

Licensure/Certifications

• Current State of California RN license (unencumbered) required.
• Certification in Infection Control (CIC) required or obtained within two years of hire.

Equal Opportunity Employer

Salary Range: $153,732 - $205,608

Assigned Work Hours: Full-time (Exempt)

Position Type: Regular

Pay Range (based on years of applicable experience): $73.91 to $98.85