Administrative Director - Infection Prevention and Control

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Position Summary

The Health System Administrative Director of Infection Prevention & Control provides strategic, operational, and regulatory leadership for infection prevention programs across the health system. This role ensures alignment with organizational goals, national standards, and evidence‑based practices to reduce healthcare‑associated infections (HAIs), support safe clinical operations, and promote a culture of safety. The Director partners closely with physician epidemiologists, entity infection prevention leaders, and system executives to drive performance, standardization, and innovation across all facilities.

Duties and Responsibilities

Strategic Leadership & Program Direction

• Provide system‑level direction and coordination of all entity‑specific infection prevention programs, ensuring alignment with DUHS goals and evidence‑based best practices.
• Develop and communicate a system‑wide vision for the identification, management, and prevention of emerging infectious diseases and trends.
• Lead development of multi‑year strategic plans for infection prevention, including standardization, performance improvement, and operational efficiency initiatives.
• Meet regularly with entity infection prevention managers and physician epidemiologists to review operations, set goals, and ensure consistent program execution.
• Coordinate the development of the annual Infection Control Report, including surveillance trends, HAI/SSI rates, accomplishments, and future priorities.
• Assist with development and maintenance of annual entity‑specific Infection Prevention plans, including evaluation of prior objectives and identification of new goals.

Regulatory Compliance & Policy Oversight

• Serve as the system’s regulatory lead and subject matter expert during surveyor visits, collaborating with entity infection prevention managers and hospital epidemiologists.
• Oversee the development, review, and standardization of infection prevention policies across the health system.
• Ensure policies and procedures reflect current national standards and regulatory requirements (CDC, Joint Commission, NHSN, OSHA, State Health Department, CMS, etc.).
• Review and update policies to maintain compliance with evolving standards and best practices.
• Assist with preparation for Joint Commission and other regulatory surveys and attend surveys as needed.

Surveillance, Data Analysis & Reporting

• Oversee the collection, validation, and analysis of infection prevention surveillance data across the system.
• Regularly review time‑trended data and support dissemination of key findings to system and entity stakeholders.
• Ensure consistent use of surveillance methodologies and definitions across all entities.
• Assist entity teams with risk assessments, including those involving multiple sites or system‑wide implications.

System Integration & Cross‑Functional Collaboration

• Partner with Quality, Patient Safety, Employee Health, Emergency Preparedness, and other departments to align infection prevention strategies with system‑wide safety initiatives.
• Collaborate with Antimicrobial Stewardship leadership to support coordinated strategies for reducing MDROs and optimizing antimicrobial use.
• Work with Supply Chain to evaluate, standardize, and implement infection‑prevention‑related products and technologies.
• Represent Infection Prevention on system committees and external professional organizations as appropriate.

Outbreak Management & Emergency Preparedness

• Lead system‑wide outbreak response activities, including coordination of mitigation strategies, communication, and reporting.
• Serve as a key leader in emergency preparedness planning for infectious disease events, including pandemics and emerging pathogens.
• Develop and maintain system‑wide protocols for surge capacity, PPE conservation, and crisis standards related to infection prevention.

Education, Training & Workforce Development

• Provide direct oversight and professional development opportunities for entity infection prevention managers and team members.
• Oversee development and standardization of infection prevention education, training, and competency assessments for clinical and non‑clinical staff.
• In collaboration with entity leadership, ensure effective processes for staff development, recruitment, and retention.

Clinical Operations & Environmental Safety

• Collaborate with departmental personnel to coordinate clinical operational activities, including staffing, space, facilities, purchasing, maintenance, and renovation needs.
• Determine and recommend necessary space, equipment, supplies, and support systems to ensure effective infection prevention operations.
• Ensure a safe environment of care for staff, patients, and visitors across all system facilities.

Construction, Renovation & Facility Planning

• Serve as the infection prevention subject matter expert for all new facilities and construction/renovation projects not covered by an existing facility leader.
• Collaborate with FPDC personnel to review architectural plans and provide infection‑prevention‑related recommendations, including:
• Dirty‑to‑clean workflow design
• Placement of hand hygiene sinks and waterless agents
• Adequate space for reprocessing instruments and equipment
• Proper airflow, ventilation, and filtration
• Support entity teams with infection control risk assessments (ICRAs) for construction and renovation projects.

Technology, Data Systems & Innovation

• Oversee selection, implementation, and optimization of infection prevention technology platforms (e.g., electronic surveillance systems, environmental monitoring tools).
• Evaluate emerging technologies and innovations that support infection prevention and recommend system‑wide adoption when appropriate.
• Promote data‑driven decision‑making and integration of infection prevention metrics into system dashboards and reporting tools.

Financial Oversight

• Facilitate budget preparation and financial control for infection prevention programs in collaboration with entity infection prevention leadership teams.
• Evaluate resource needs and ensure appropriate allocation to support effective infection prevention operations.

Required Qualifications at this Level 

Education  

Bachelor’s Degree required. Master’s Degree preferred.

Experience   

Work requires seven years of progressive administrative leadership experience, 3-5 years in a hospital infection prevention preferred.

A Master's degree in Hospital Administration, Business Administration or a related field may be substituted for experience on a 1:1 basis.

OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE 
  

Degrees, Licensure, and/or Certification  

Master’s Degree  - preferred

Certification in Infection Control & Epidemiology (CIC) 

 
Knowledge, Skills and Abilities 

• Strong ability to manage and facilitate multiple organizational priorities and missions using consensus‑building and negotiation skills.
• Deep understanding of clinical disciplines, healthcare operations, and issues impacting patient care.
• Knowledge of cost‑containment strategies and their implications for infection prevention.
• Ability to work effectively with diverse individuals and teams across multiple settings and locations, fostering an inclusive and collaborative work environment.
• Proven ability to build positive, productive relationships with physicians, nurses, department leaders, administrators, frontline staff and other worker types within the organization.
• Proficiency with Microsoft Office applications, including Word, Excel, Access, PowerPoint, Teams, and Outlook.
• Ability to facilitate and manage NHSN data submissions and ensure accuracy and compliance with reporting requirements.
• Comprehensive knowledge of infection prevention, surveillance methodologies, regulatory standards (e.g., Joint Commission), and current literature.
• Commitment to professional engagement, including participation in local and national APIC and/or SHEA activities; involvement in infection‑prevention‑related research is encouraged.
• Excellent communication skills, including strong verbal presentation abilities and high‑quality professional writing.