System Director Hospital Epidemiology and Infection Prevention

The Director of Hospital Epidemiology and Infection Prevention (HEIP) is responsible for directing all infection prevention activities of UCSF Health and its licensed facilities in partnership with the HEIP Medical Directors for the adult and BCH-SF and BCH-Oakland pediatric services, functioning within a dyad leadership structure. Under the general direction of the Vice President for Quality and Patient Safety, and in collaboration with the HEIP Medical Directors, the Director provides expertise, strategic direction, leadership, planning, organization and general management for all aspects of HEIP at UCSF Health. This includes but is not limited to:

• Developing, directing, and prioritizing activities related to the institutional Infection Prevention program for adult and pediatric populations at Parnassus, Mount Zion, Mission Bay, Oakland, Langley Porter Psychiatric Institute, Stanyan, Hyde, and UCSF Health-licensed ambulatory services in collaboration with the Medical Directors

• Responsibility for creating a structure for daily, twenty-four (24) hour planning, organizing, directing, controlling, and consultation of daily operations in order to support an environment that optimizes the mission and priorities of the HEIP department 

• Ensuring prompt responses, information exchanges, and issue resolution in response to questions relevant to UCSF Health infection prevention policies and practices

• Ensuring accurate and timely reporting of all mandated legal, regulatory and institutional infection-related surveillance data

• Directing activities for institutional compliance with The Joint Commission (TJC) accreditation Infection Prevention and associated standards for the hospital and laboratory programs and other certifications, California Department of Public Health (CDPH) reporting regulations, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) for Hospitals, Transplant Services, and ESRD

• Providing direction for the managers of the Field Unit and Surveillance and Clinical Analytics Unit who oversee operational management of Field Unit and Surveillance and Clinical Analytics Unit HEIP personnel 

• Managing assets within a 4.6 million budget

• Working collaboratively with other groups within the Department of Quality and Safety including Regulatory Affairs and Patient Safety, Risk Management, Patient Relations, Nursing, Hospitality, Facilities and Design & Construction, Environment, Health, and Safety, Occupational Health Services, and other Core services to assure alignment of regulatory, quality, risk and patient safety initiatives

• Ensuring institutional infection prevention-related preparedness for epidemic and pandemic responses including emerging and high consequence pathogens

• Developing partnership with and Interfacing with all levels of the organization

• Publicly representing HEIP in institutional and public forums

• Liaison to the local Department of Public Health and the state Healthcare Associated Infections program

• Recruiting and developing highly skilled, diverse and engaged team members

Department Overview:

The Department of Quality & Safety consists of Adult Quality & Safety, Benioff Children’s Hospitals (BCH) Quality & Safety, Hospital Epidemiology & Infection Prevention, Regulatory Affairs, Health Equity and Clinical Documentation Integrity. The teams are made of multidisciplinary professionals with diverse backgrounds. The role of the Department is the support UCSF Health to deliver safe, equitable and high-quality care to the communities we serve.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(Tobe completed by Supervisor)

10

Yes

Leads strategic planning and design of all Infection Prevention activities across the UCSF Health system in partnership with the HEIP Medical Directors,including setting cohesive institutional strategy and priorities,

developing and shepherding approval of the annualIP plan in order to meet external and institutional goals for patient outcomes in collaboration with the HEIP Medical Directors

10

Yes

Directs and participates in acquiring information to interpret and communicate current science regarding all levels of infection prevention requirements and standards

10

Yes

In collaboration with the HEIP Medical Directors and health system partners, leads and directs the planning, design, implementation and evaluation of institutional infection prevention improvement projects as commissioned by the Infection Prevention Committee and related UCSF Health committees and in collaboration with key partnerships within and outsideof UCSF Health

10

Yes

Collaborates with the HEIP Medical Directors, HEIP Surveillance and Clinical Analytics Manager and Field Unit Manager, along with other institutional leaders  toassure alignment of infection prevention, quality and patient safety goals and initiatives

10

Yes

Directs compliance with and responses to policies, systems, processes and stafftraining to support successful institutional response to unannounced accreditation and

certification surveys and site visits;leads and directsinvestigation and follow-up of infection-related complaints and findings

10

Yes

Directs andoversees technical andadministrative development, evaluation, acquisition, implementationand ongoing integrity of data systemsto meet regulatory and institution- required reporting, to integrate infection prevention data into the broader institutional

data analytics plan for data management, and to translate infection prevention data into actionable information at all levels of the organization

10

Yes

Leads and directs the development, evaluation, acquisition and implementation of educational materials to further compliance with infection prevention strategies at all levels of the organization, by all patients, students, staff and faculty

10

Yes

Recruits, develops, retains and manageshighly skilled departmental staff, and through strong leadership maintains a highly engaged team

5

Yes

Directs infection prevention staff assignments, activities and time to efficiently and effectively carry out the priorities of the annual Plan

5

Yes

Communicates effectively directly and indirectly through policies, education, systems, activities to operational leaders and all levels of the organization; along with the HEIP Medical Directors, represents HEIP across the health system in interdisciplinary committees; advises senior management on a range of topics impacting institutional infection prevention-related safety.

5

Yes

Maintains active professional contacts through local, state, national and international associations; prioritizes and participates in shared leadership for the UCOP Healthcare

Epidemiology Collaborative

5

Yes

Other dutiesas assigned

100%

(Toupdate total %, enter the amount of time in whole numbers(without the % symbol - e.g., 15, 20) then highlight the total sum(e.g., 1%) at the bottomof the columnand press F9. The

total sum should add up to 100%.)

Minimum Requirements:

• Master’s degree in Nursing, Business Administration, Health Care Administration, Public Administration or other health-related field
• Minimum five years of experience in infection prevention management
• Certification in Infection Prevention
• Comprehensive knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments
• Comprehensive project management, interpersonal, and communications skills to effectively convey complex information and instructions both verbally and in writing, and to cultivate a strong commitment to teamwork, quality, and achievement of objectives
• Serves local and national professional organizations in leadership roles
• Strong leadership skills and fiscal management skills, with the ability to create a goal-oriented climate of teamwork, collaboration and consistent achievement of objectives
• Strong analytical, organizational, and problem-solving skills, with ability to identify system vulnerabilities and develop and apply innovative solutions
• Serves local and national professional organizations in leadership roles
• Demonstrates strong hospital management experience and advanced expertise in and knowledge of infection prevention, quality improvement methodologies and management in an academic facility
• Strong leadership, interpersonal and communications skills to promote, support, and introduce infection prevention systems and processes across a broad spectrum of departments
• Strong ability to convey complex information clearly and concisely to all levels of staff, management, and outside personnel, with the ability to motivate, influence, and persuade others
• Strong ability to organize, manage multiple priorities, meet deadlines and assign work efficiently

Preferred Qualifications:

• Clinical license in a healthcare-related field