About The Role

Company Overview

Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.

With 20+ hospitals, outpatient clinics, ambulatory care centers and outreach locations across the globe, we provide excellent care to children up to age 18 regardless of their family’s ability to pay or insurance status. Please click here to learn more about our locations.

CURRENT EMPLOYEES : Please log into Workday Click Here to apply internally through the "Jobs Hub"

Job Description

The Performance Improvement & Infection Control Program Manager works with the ASC staff, leadership and medical staff to ensure the facility is optimized to improve outcomes and efficiencies, increase capacity, minimize risk, and provide safe, timely, cost-effective, compassionate, coordinated, patient and family centered care, while ensuring compliance with Shriners Children’s local, state and federal regulations and requirements, as well as ethical practices. This role also contributes to the overall strategic vision of the infection prevention and control program. This includes identifying, investigating, monitoring and reporting healthcare-associated infections, as well as system-wide infection prevention initiatives that impact all business units within the facility. This role acts as the site subject matter expert in infection prevention, who collaborates with teams and individuals to create infection prevention strategies, provide feedback, and sustain prevention measures.

Position Responsibilities

Lead and manage the organization's quality, performance improvement, patient safety, and infection prevention programs, ensuring compliance with regulatory, accreditation, and organizational standards.
Develop, implement, and monitor policies, procedures, and performance improvement initiatives that promote high-quality patient care, safety, and operational excellence.
Serve as a subject matter expert and resource for staff and leadership on quality improvement methodologies, infection prevention practices, risk management, and patient safety strategies.
Oversee infection prevention activities, including surveillance, investigations, reporting, staff education, outbreak response, and implementation of evidence-based infection control practices.
Monitor healthcare-associated infections, review microbiology and surveillance data, and identify opportunities to reduce infection risks and improve outcomes.
Ensure compliance with federal, state, and accreditation requirements, including CMS, The Joint Commission, CDPH, and mandatory reporting obligations.
Coordinate accreditation readiness activities, mock surveys, regulatory reviews, corrective action plans, and licensing support.
Investigate incident reports, patient complaints, grievances, and safety events, ensuring timely resolution, documentation, and corrective actions.
Lead patient safety initiatives, including Root Cause Analyses (RCAs), Failure Mode and Effects Analyses (FMEAs), and culture-of-safety programs.
Collaborate with multidisciplinary teams to improve clinical quality, patient satisfaction, environmental safety, and risk reduction efforts.
Educate and mentor staff on quality, safety, infection prevention, and performance improvement processes while fostering a culture of continuous improvement and accountability.
Ensure organizational compliance with ADA, disability regulations, and other applicable healthcare laws and standards.