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RN Patient Safety
Infection Prevention Specialist

The RN Patient Safety and Infection Prevention Specialist will lead, develop, implement, and facilitate the Pemiscot Memorial Health Systems (PMHS) enterprise Patient Safety and Infection Prevention Program and connect nursing practice to quality, safety, patient experience, and regulatory programs. The Patient Safety and Infection Control Specialist serves as a departmental and organizational expert for the Patient Safety and Infection Prevention Programs. Under the management of the Director of Quality, the incumbent is primarily responsible for administration of our online reporting systems, organizational training, and data collection.


The incumbent, in collaboration with Chief of Staff and PMHS leadership team, oversee processes to ensure reliable performance around preventive and clinical outcome goals. The incumbent will use analytics to track and trend performance and create feedback mechanisms to operational teams. The incumbent works with internal and external teams to drive success and promotes a culture of safety and interdisciplinary collaboration. This individual will foster teamwork and champion service excellence throughout the organization. The incumbent interacts with various PMHS departments and leaders to develop infection prevention and safety monitoring systems that drive change. The Patient Safety and Infection Prevention Specialist is specialized in data management while qualified to facilitate process improvement when needed.

Job Description & Requirements

Major Responsibilities:

  • Conducts daily rounds in clinical areas to observe infection control risks such as IV tubing placement, central lines, dressing changes etc. are in compliance with infection prevention and patient safety

  • Help monitor, assure, and coordinate Patient safety activities are in compliance with requirements of regulatory, accrediting agencies, ACO and other payer contracts identifying safety expectations. Identify and communicate need for corrective actions as appropriate.

  • In collaboration with Regulatory roles, monitor Sentinel Event Alerts and facilitate team to analyze the safety of our organization based on the SE Alert information when needed.

  • Responsible for working with Risk Management, legal counsel and others to create and ensure a robust process for monitoring, prevention, event mitigation, event reporting, and triaging.

  • Work collaboratively with all levels of the organization including senior leadership to produce measurable improvements in patient safety in both process and outcome.

  • Collaborate the development of policy and procedures effecting organizational safety. Translates safety policies, theories and strategies into action.

  • In collaboration with the Director, responsible for building and implementing safety systems and the promotion of the culture of safety which are paramount foundations.

  • Implement and evaluate a regularly scheduled Culture of Safety Surveys – frequency to be determined with leadership.

  • Responsible for the RCA and Proactive Risk Assessment team process, including but not limited to initiating a team, creating, and communicating to the team, participation of teams, assuring standard reporting, meeting Sentinel Event requirements and deadlines, ensuring team action items are completed, developing status reporting to RCA Subcommittee, and creating status reports for leadership committees.

  • Administratively responsible for planning, management and implementation of patient safety initiatives across the organization, including National Patient Safety Goals, among others, meeting milestones, deadlines, and deliverables that position UW Health as a patient safety leader, including education and communication plans.

  • Provide support and guidance to the PMHS Resident Quality & Safety Council/Meeting (RQSC).

  • Help create, establish, maintain, and staff the PMHS Safety Committee.

  • Staff and provide safety expertise to the RCA Subcommittee.

  • Encourage and promote staff involvement and engagement.

  • Contribute to the development of budgets.

  • Lead selected organization improvement teams to stay current with skills.

  • Enable teams across the organization to become experts at guiding their own improvement.

  • Directs the development, planning and implementation of the strategic initiatives of the infection prevention program across all PMHS locations.

  • Connects with nursing leadership and nursing governance on the development and deployment of system initiatives related to quality, safety, patient experience, and regulatory readiness at all PMHS locations

  • Identify opportunities and clinical problems and guide team members in the development and implementation of evidence-based, highly reliable clinical practices that lead to desired quality outcomes.

  • Researches and develops future strategic direction for infection prevention at the system level by collaborating with the PMHS leadership team, external organizations, and local and state authorities

  • Collaborate with cross functional leaders throughout the organization to improve processes related to high quality and safe nursing care and infection prevention.

  • Directs the communication of infection prevention and nursing initiatives to improve quality and safety to operational leadership, executive leadership, and clinical leadership.

  • Conducts ongoing assessment and state of compliance for applicable regulations and standards. Directs performance improvement efforts in areas of insufficient compliance.

  • Serves as a resource on applicable regulations and standards. Stays abreast of proposed and new regulations and standards and initiates actions to ensure compliance in collaboration with the PMHS regulatory team.

  • Reviews and evaluates services related to nursing practice and infection prevention that are affected by medical safety/regulatory issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that safety/regulatory recommendations are implemented, and the desired results are obtained.

  • Directs the infection prevention team at all locations to review and evaluate services related to infection prevention. Assures the infection prevention team at each location works collaboratively with cross functional team members to identify problems, make recommendations for improvement, and monitor services to ensure that safety/regulatory recommendations are implemented, and the desired results are obtained.

  • Provides direction for teams to develop and coordinate educational programs related to infection prevention.

  • Participates in the system Quality, Safety, and Regulatory teams.


  1. Education:  Associates’ Degree in  Nursing, Healthcare, Health Information Management, Science, Communications, Business, or related field, or equivalent combination of experience and education.  Bachelor’s degree in Nursing, Nursing Informatics, Information Technology, Business or degree related to applicable department preferred.

  2. Work Experience:  One (1) year of progressive experience in infection prevention practices, patient safety practices or facilitating interdisciplinary improvement teams in a healthcare setting, or other relevant experience.  Two (2) or more years experience preferred.

  3. Required Skills,Knowledge, and Abilities:

    • Knowledge of and ability to use computers, including word processing, spread sheets, graphics, and database management.  

    • Ability to work well with online data systems, including the ability to understand key functions to optimize use of the system as well as educate others on use of the system.

    • Strong ability to track data, analyze and interpret numbers, and make recommendations based on data synthesis in a clear and logical representation to management and peers.

    • Ability to work with diverse teams representing various disciplines and all levels of staff.

    • Excellent communication and active listening skills. Ability to negotiate collaborative efforts with other departments.

    • Skilled at facilitating a group process, building teams, and transferring knowledge and skills.

    • Able to demonstrate strategic thinking to guide alignment with organizational goals and priorities.

    • Ability to problem solve, make independent decisions, formulate reports, perform statistical analysis, and interpret data.

    • Ability to work independently, be result oriented, manage multiple priorities, and frequent change in duties and volume of work.

    • Ability to maintain confidentiality of sensitive information.

    • Able to handle medium to large scale projects involving multiple resources and spanning many months from start to finish.

    • Ability to educate-non punitively- on patient safety and infection prevention and provide just in time training

    • Ability to build a collaborative and cohesive patient centered, team based Culture

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