Infection Prevention, Accreditation, and Regulatory Associate

Position Summary / Career Interest:

The Infection Prevention, Accreditation, and Regulatory Associate supports activities that promote compliance with accreditation, regulatory, and infection prevention requirements and related performance improvement projects. The Associate performs various data management functions necessary for continuous survey readiness and for the hand hygiene, personal protective equipment (PPE), and cleaning and disinfection programs including, but not limited to, providing real-time observations in clinical settings, providing real-time feedback and coaching to front-line staff, data collection, chart reviews, data entry, maintaining data integrity, performing data validation, and conducting basic data analysis. The Associate assists members of the Accreditation & Regulatory and Infection Prevention & Control teams to respond to data requests, data dissemination, implementation, and evaluation of performance improvement projects intended to meet the organization's vision to lead the nation in caring, healing, teaching, and discovering.

Responsibilities and Essential Job Functions

• Supports various initiatives to maintain accreditation, regulatory compliance, facility-level professional certifications, and other internal and external quality and safety programs.
• Takes an active role in hospital survey readiness and Infection Control regulatory preparedness activities.
• Supports the day-to-day functions of the hand hygiene, PPE, and cleaning and disinfection programs, including quality improvement observations and data collection.
• Conducts chart reviews and enters data into systems for analysis and trending.
• Performs basic data analysis and manipulation using Microsoft Office (Excel, PowerPoint); shares and presents data and findings to internal audiences and healthcare staff.
• Provides real-time coaching and feedback on observed compliance opportunities.
• Validates and monitors post-survey action plans.
• Supports management of improvement projects, including educational events, campaigns, and evaluation of new technologies.
• Provides training and education on accreditation, regulatory, hand hygiene, PPE, and cleaning and disinfection concepts; assists with ongoing training and onboarding of new hires in a classroom setting.
• Provides technical policy support.
• Performs various quality assurance activities.
• Participates in local, regional, and national accreditation, regulatory, and infection control related educational offerings and meetings.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Associates Degree OR
• Licensed Practical Nurse
• 1 or more years experience in healthcare, public health, or a related field.

Preferred Education and Experience

• Associates Degree

Knowledge Requirements

• Proficient in MS Office
• Ability to speak and train groups of employees
• Interacts in a courteous, professional manner with evidence of conflict resolution skills
• Demonstrates collaborative working relationships and works under the direction of the assigned department manager and/or director

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.