Director- PeriOperative Services Infection Control/Regulatory Compliance- HUP

Responsibilities:

• Employee Engagement:
• Regularly meets with key stakeholders to improve communication and to build productive relationships.
• Regularly meets with teams to enhance communication and collaboration.
• Continuously communicates regulatory initiatives and readiness efforts for improving performance in meeting and exceeding expectations.
• Designs and implements systematic and consistent regulatory processes.
• Develops and supports an environment of regulatory readiness and vigilance.
• Internal Partnerships:
• Works with Perioperative Services executive team in developing programs, services and initiatives to become a High Reliability Organization.
• Sets standards and drives operational integration of regulatory efforts by ensuring alignment across teams, environments and entities.
• Establish/update processes and work practices for regulatory compliance:
• Manage and eliminate process workarounds by appropriately and consistently sharing with organizational partners the issues, which require their attention.
• Analyze the data regularly to identify opportunities for improvement.
• Share data with teams and mutually identify opportunities for improvement within the department’s span of influence.
• Collaborate with teams to develop action plans for improvement.
• Implement and follow through with action plan.
• Manage team and individual performance in alignment with the UPHS vision of service excellence:
• Drive regulatory loyalty by ensuring staff understand the UPHS commitment to service, their own work processes, and have the necessary skills to meet regulatory standards through education, support and surveillance.
• Focus energies on collaborating in problem resolution rather than finding blame.
• Ensure that teams understand regulatory standards.
• External Relationships
• Understands the needs and expectations of patients, referring physicians, faculty and staff of UPHS and other affiliates
• Ensures patient and customer satisfaction through comprehensive and continuous measurement of customer satisfaction for all key customer groups.
• Participates in industry benchmarking as appropriate.
• Works collaboratively with PeriOp departmental and clinical leadership throughout all UPHS entities
• Operations:
• Regulatory Compliance – ensures compliance with all federal, state and local regulatory standards and requirements, including JCAHO, DOH, funding agencies, FDA, HIPA and others.
• Provides oversight for master cleaning plan for clinical and non-clinical areas in compliance with all regulatory agencies.
• Oversight of “Environment of Care” Standards.
• Provides oversight for management of TDOC instrument tracking system implementation and use.
• Provides guidance to manage process deficiencies in instrument life cycle as identified by TDOC reports.
• Oversees and ensures sterilization / high-level disinfection processes for PeriOperative Services meet or exceed established standards.
• Provides oversight to the pick list / preference card functions (database maintenance, creation and maintenance of case lists).
• Oversees and conducts investigation of monthly expense variations for all PeriOperative a/u’s
• Identifies and initiates cost savings and standardization opportunities throughout the department, and across entities.
• Oversight and management of all construction projects and facilities improvements in PeriOperative Services. Ensures that patients and staff are safe and protected during construction projects.
• Represents PeriOperative Services in the development and implementation of capital and operating budget.
• Develops and implements Infection Prevention and Control programs and processes for HUP Perioperative services ant the Offsite Interventional Support Center.
• Implements surveillance programs and activities to proactively identify opportunities for improvement and interventions to reduce healthcare-associated infections.
• Responsible for implementation and supervision of these programs, as well as efforts to insure a safe workplace for HUP Perioperative Services and the Offsite Interventional Support Center.
• Designs and completes analysis of data regarding prevention and surveillance activities. Reports data and information to PeriOp Unit Based Clinical Leadership Team (UBCL), the Infection Control Committee and required regulatory agencies.
• Assists PeriOp Quality Committee and PeriOp Executive Committee in interpretation of healthcare-associated infection data and in the development of interventions in response to the data.
• Establishes and monitors Infection Control policies and procedures to insure compliance with The Joint Commission and State and City Department of Health regulations.
• Oversees compliance with Pennsylvania mandatory public reporting legislation.
• Provides subject matter expertise and internal consultation on infection prevention and control to HUP Perioperative Services and the Offsite Interventional Support Center.
• Initiates investigation of outbreaks of healthcare-associated infections and recommends immediate action to contain and prevent future occurrences.
• Participates in and collaborates on health system-wide infection prevention and control activities.
• Develops and delivers education programs on infection prevention and control to PeriOp and Offsite staff.
• Develops effective communication plan for all stakeholders to build awareness of effective infection control practices to reduce and prevent infection.
• Represents the department on many Hospital committees and initiatives. Regularly presents at Department Director and Leadership meetings.
• Partners with Facilities and Maintenance departments in all major construction and renovation projects to insure safe working and patient care environments.
• Inform Senior Leadership of resource utilization.
• Successfully negotiates and advocates for resourcing needs across boundaries with partners as appropriate.
• Strategic Planning Processes:
• Develops standardized communication plan that is aligned with the organization-wide vision
• Recognizes and acts on opportunities to advance the organization’s regulatory compliance
• Develops and implements work plans with actionable components and measurable outcomes
• Proactively monitors regulatory performance
• Change Management
• Proactively develops change management strategy for major organizational activities and events
• Implements change management strategy in alignment with UPHS objectives.
• Identifies and facilitates agreement of major messages which are consistent regardless of audience, credible and reflects UPHS’ core values
• Communication plans are effectively implemented
• Ensure appropriate follow-up of major issues
• Manage routine and crisis communications throughout the entity/community as they arise
• Demonstrates recognition of the systemic impact of employee communication and/or policy changes and solicits proactive feedback prior to implementation.
• Evaluates effectiveness of change and implementation plans.
• Regulatory Compliance
• Creates a vision for advancing a culture of regulatory compliance within HUP PeriOp and Offsite staff..
• Collaborates with HUP and Penn Medicine senior leaders to identify priorities for regulatory readiness, and cultivates key partnerships for execution of regulatory compliance initiatives.
• Partners with HUP PeriOp and Offsite leaders to ensure alignment of operational and regulatory agendas.
• Seeks and maintains partnerships to promote regulatory compliance.
• Leads managers and leaders towards common standards of compliance
• Aligns regulatory practices across service lines
• Cultivates a strategic program of regulatory compliance
• Leverages the expertise and knowledge of internal and external regulatory experts.
• Leads and influences all staff to consistently practice regulatory standards.
• Creates, manages, analyzes, and presents data from regulatory efforts.
• Disseminates regulatory findings through standardized communication plans.
• Strategically integrates regulatory compliance with HUP and Penn Medicine goals and initiatives.
• Creates a regulatory culture through engagement, vigilance and support for all employees.
• Promotes shared accountability
• Evaluates effectiveness of regulatory integrated initiatives.
• Engages with staff in all roles and scopes of practice to promote a culture of regulatory compliance
• Participates in the development of innovative programs/ strategies to educate staff and leaders about
• regulatory standards and practices.
• Consults with and advises staff around aspects of regulatory compliance.
• Mentors, supports and coaches staff in aligning daily practice with regulatory standards and behaviors.
• Partners with and guides staff in all steps of the regulatory process
• Supports a creative learning platform for frontline staff
• Establish/update processes and work practices for the unit/department.
• Build work practices and team processes based on the Institute of Medicine’s (IOM) Six Aims for Improvement:
• Safe: avoid injuries to patients form the care that is intended to help them.
• Effective: provide services based on scientific knowledge.
• Patient-Centered: provide care that is responsible to individual patient preferences, needs and values and assuring that patient values guide all clinical decisions.
• Timely: reduce waits and sometimes-harmful delays for both those who receive care and those who give care.
• Efficient: avoid waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status.
• In conjunction with all stakeholders involved in regulatory processes, institute operational changes based on data.
• Communicate, reinforce, and update as necessary environment of care procedures, (e.g. safety, security, hazardous materials, emergency, medical equipment, and utility management.)
• Continuously improve unit/department operations to maintain and exceed internal/external regulatory compliance and achieve clinical excellence.
• Participates in and supports research safety goals and initiatives (FMEA,RCA)
• Regulatory Compliance:
• Ensures compliance with all federal, state and local regulatory standards and requirements, including JCAHO, Department of Health, funding agencies, FDA, HIPAA, HCFA, DPW and others.
• Support all specialty surveys (transplant, heart failure, stroke) affecting Perioperative Services and the Offsite Interventional Support Center
• Identify the regulatory requirements for the patient populations served (neonate, child, adolescent, young adult, middle adult and older adult)
• Core Values
• Proactively shares information and trends.
• Demonstrates fair and appropriate due process in actions and decisions.
• Recognizes risk taking and promotes it in others.
• Exhibits an openness to change and promotes it in others.
• Demonstrates personal ownership for UPHS decisions.
• Ensures confidentiality.
• Creates a work environment that attracts and retains key talent.
• Facilitates the identification of common goals.
• Treats people respectfully.
• Effectively manages and efficiently uses all resources.
• Is open to and respects differences, ideas, and suggestions.
• Does not participate in non-productive activities of conversations.
• Maintains confidentiality.
• Establishes and maintains good working relationships and partnerships.
• Adheres to established policies and procedures.
• Always seeks clarity to ensure understanding, keeps work processes reasonable and simple, and
• balances priorities.
• Effectively communicates and ensures understanding of UPHS’ mission, vision, and values.
• Makes and keeps commitments.
• Meet deadlines and is responsive to requests.
• Exemplifies in his/her action principles of collegiality and collaboration at all times.

Education or Equivalent Experience:

• Bachelor of Arts or Science in Business, Nursing and/or Health Care
  (Required)
• Master of Arts or Science in Business, Nursing and/or Health Care (Preferred)
• 10+ years Leadership experience in an academic health care setting (Required)
  
• Working clinical knowledge of Perioperative Services (Required)