Job Description


The Infection Control Program Manager support the IC Program Director in oversight of hospital operations specific to the prevention, control, documentation and reporting of nosocomial acquired infections and communicable diseases throughout all Steward Health Care facilities and services. The manager will evaluate hospital compliance of practices that are associated with the prevention and control of healthcare-associated infections. The Infection Control Program Manager will monitor and support the evaluation of the hospital based infection prevention and control program that is consistent with the Centers for Disease Control and Preventions recommendations, TJC Standards, OSHA and DPH regulations and current published literature in the field of Hospital Epidemiology.
The Infection Control Program Manager will be responsible for the administration of the IC surveillance program for the entire network of infection control programs and will provide development, oversight and consultative services to all areas, both clinical and non-clinical.
IC Surveillance Software: Knowledge includes, but is not limited to:
• Software functionality and features
• Software configuration capabilities and tools
• User roles and scope for configuration and maintenance
• Alert configuration and maintenance
• Report generation
• Auto-reports configuration and maintenance
• Interface management with hospital EMR as well as NHSN for public reporting
• The Manager will configure the software to meet organizational requirements. The Manager will also provide support to end users with configuration needs and issues prior to calling their internal IT Help Desk and/or the event reporting software Support Team.

Assists the IC Program Director, Executive Directors of Patient Safety as well Quality and Regulatory Affairs and the Chief Medical Officer with the implementation of the System-wide Quality and Safety Plan consistent with board approved plans and regulatory and standard setting agencies.


IC Surveillance Program Responsibilities during Implementation:
• Perform the configuration requirements of the software with guidance from vendor
• Learn all configuration components of the software
• Act as the primary resource to train all users
• Clearly communicate the requirements of the system to the system's users
• Provide troubleshooting of configuration issues and questions raised by end users
• Have a working knowledge on file entry, file management, and reports to help with configuration responsibilities
• Liaise between leadership and the users with regards to policies, procedures, and configurations for the system
• Follow the internal change management process for software configuration changes
• Escalate issues to the necessary party for resolution

IC Surveillance Responsibilities after Implementation:
• Be responsible for performing on-going software configuration needs
• Continue to function as a bridge between leadership and the users of the system in relation to policy, procedure and configurations to the system
• Escalate issues to the necessary party for resolution
• Manage the internal change management process for tracking on-going software configurations
• Act as primary troubleshooting of configuration issues and questions raised by end users
• Take initiative to develop and maintain advanced configuration skills
• Create and run corporate-level reports, and other reports as required
• Maintain user list based on personnel changes, maintain auto-reports configuration, and maintain alert configurations
• Coordinate with internal IT resources to apply updates when delivered by vendor
• Stay current on new software versions released by the vendor

Surveillance and Data Analysis:
• Reviews all hospital on-going surveillance using appropriate IC criteria, documentation and investigation of Hospital Acquired Infections (HAIs) through review of IMPRO/NHSN online documentation.
• Supports the evaluation of effectiveness of the System Infection Control Program
• Reviews and interprets data in support of epidemiological studies of specific problem areas to determine the source of the problem and to make recommendations at the local hospital infection control committee
• Supports the analysis of the system infection control data to include risk assessment, prevention and control strategies.
• Attends hospital infection control committee meetings to support program progression and compliance with identified strategies to reduce risk from infections when requested
• Attends hospital HAI committees to ensure performance improvement strategies are consistent with system plans and goals when requested.
• Works with hospital risk managers to report infection outbreaks to the appropriate regulating bodies.

Performance Improvement:
• Supports quality improvement activities by assessing, monitoring, and measuring HAI rates and evaluating outcomes on a continuous basis
• Participates in hospital organized pi activities specific to infection reduction strategies.
• Supports infection control activities as it relates to other improvement strategies, ie Immunization programs, hand hygiene, surgical care, pneumonia and sepsis reduction strategies, etc

• In conjunction with Infection Control Committees, plans, organizes implements and evaluates educational programs for all Steward Personnel, including administrative and ancillary staff, to enhance skills, knowledge and awareness of HAIs, avoidance techniques, and preventative measures.
• Conducts regular training sessions to ensure consistent implementation of IC practices at the direction of the program director
• Develops educational materials that are relevant, useful and easily understood by both clinical and non-clinical personnel.
• Serves as knowledgeable resource on IC practices and policies for patients, families and staff.

• Maintains compliance with all standards from CDC, TJC, CMS, DPH, Local Boards of Health, OSHA, etc
• Assists with licensing/accreditation survey preparation as needed.
• Maintains an updated Infection Control Manual for use by all hospital ICPs.


• Shall support the on-going integration of the System Infection Control Program under the System Quality and Safety Plan
• Shall support the development and update of all relevant departmental/hospital policies and procedures specific to infection control
• Shall be accountable for maintaining the confidentiality and security of all hospital related, medical staff related and patient related data and information
• Accountable for the timely and complete review and investigation of all incidents and grievances reported into the department associated with infection control activities as reported by the Hospital Risk Manager


• 5 - 10 years' experience in hospital infection control program.
• Graduate of an accredited Baccalaureate nursing program, Master of Science in Epidemiology and/or Public Health, or a Masters of Science in Nursing or Medical Technology.
• Certification Board for Infection Control and Epidemiology (CIC) required
• Knowledgeable in fields related to infection control, microbiology, patient care practices, clinical infectious diseases, pathology, medical statistics or biostatics, epidemiology and adult education principles.
• Experience in Information Technology as applied to Infection Control or Public Health, with a working knowledge of and ability to use online services for research, i.e., rL Solutions IMPRO, NHSN, Sentri 7, etc.
• Knowledge of performance improvement monitoring and development of performance improvement indicators.
• Excellent written, oral and presentation skills, including knowledge and experience in grant writing.
• Demonstrated assertiveness, conflict resolution, negotiation and collaboration skills and customer focused interpersonal skills.
• Demonstrated experience designing, implementing and leading full-continuum, multi-hospital Infection Prevention and Control Programs.
• Must be able to travel to other Steward entities as needed


• Collaborates with the following staff, by job category:
• Hospital Infection Control Practitioners
• Hospital Employee Health Professionals
• Corporate Director of Quality Metrics
• Corporate Patient Safety System Administrator
• Serves on Corporate committees as directed including but not limited to:
• Infection Control Enterprise Committee
• Enterprise Groups supported by Value Analysis team
• Infection Control/Employee Health Enterprise Committee
• Collaborate quality initiatives to support the reduction of hospital acquired committees


• Under the general supervision of the Program Director of Infection Control, ensures ongoing improvement and compliance of the System Infection Control Program
• Manager assists with the day to day over sight of hospital implementation of the system's approved Infection Control Program
• Oversee and reviews all hospital acquired infections identified and reported through Hospital Surveillance Program through NHSN reporting tool.
• Oversees activities of the hospital based Infection Control Practitioners to ensure compliance with system Infection Control Program.

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