Project Manager-Infection Control & Clinical Compliance
Brigham & Women's Faulkner Hospital(BWFH)

Boston, Massachusetts


Provides project management to support functions of Clinical Compliance and Infection Control departments to ensure effective departmental operation and optimal communication of departmental priorities regarding infection control and compliance throughout the hospital

Assists with data collection, analysis and display for presentations to internal and external stakeholders

Supports project management for Infection Prevention and Control, and Clinical Compliance and other Quality and Safety teams as needed

Reports to the Senior Project Manager Infection Control and Compliance

Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.

Supports hospital personnel and service chiefs in facilitating quality improvement projects related to infection control aligning with regulatory mandates. The Infection Control/Compliance Project Manager works with the team to assure hospital compliance with federal and state regulatory, and accreditation requirements. The Project Manager communicates requirements of the compliance process to hospital committees and staff.

Assists hospital staff in developing analytic and measurement strategies for Infection Control Quality Improvement projects. Supports projects associated with emerging infectious diseases and pandemic related activities.

Participates in data collection and data entry activities as directed to support Joint Commission Core Measures, CMS's National Hospital Quality Measures, Massachusetts Department of Public Health, Boston Public Health Commission and NHSN/CDC quality measurement and reporting requirements.

Participates in data analysis and population review as well as ad hoc medical record chart reviews to investigate quality trends and identify gaps or areas for improvement; works with Senior Infection Control Quality Analyst/Compliance Project Manager to support the Executive Director and Infection Control Preventionist within the department, as well as physician leaders and nurse directors, to summarize findings, develop recommendations for corrective actions or improvement projects as needed, and track the impact of implemented changes.

In coordination with the Executive Director and the Infection Control Practitioner, develops agenda and content for the Infection Prevention and Control Committee and the Antibiotic Stewardship Committee. Supports Infection Control Policy development and/or review.

Works with hospital department directors, department quality leaders/representatives and service chiefs to develop annual quality measurement and improvement plans connected to Infection Control and Compliance measures, including identification of measures to be tracked locally versus centrally. Acts as a resource to departmental quality leaders and service chiefs.

Establishes effective and collaborative working relationships with members of the hospital community, clinical departments, administrative departments, hospital committees, and quality and safety staff across the Mass General Brigham System as needed.

Keeps current with data abstraction specifications in Infection Control and in Joint Commission Standards to address emerging trends, changes and reporting initiatives. Integrates key concepts into work across hospital.

Facilitates readiness and preparation for all DPH, Joint Commission and CMS site visits ensuring proactive compliance with regulations and standards.

Assists with on-site surveys.

Facilitates completion of regulatory after-action components following any site survey.

All other duties as assigned.

Brigham and Women's Faulkner Hospital is a 171- bed non-profit, community teaching hospital located in Jamaica Plain directly across the street from the Arnold Arboretum. Founded in 1900, Brigham and Women's Faulkner Hospital has a long history of meeting the health care needs of our patients by offering comprehensive care in a wide variety of specialties. At Brigham and Women's Faulkner Hospital, our world revolves around our patients and their families, which is why we've been nationally recognized for our best practices in patient care, safety measures and surgical outcomes. If you're looking for more than a career, join Brigham and Women's Faulkner Hospital. Our patients call it better care. Our employees call it home.


Staff adheres to all I C.A.R.E. Standards

Microsoft Office required. Additional data computing and strong electronic data base skills preferred.

Strong organizational and interpersonal communication skills required

Strong data analysis and data display skills required

Must demonstrate maturity and discretion to handle confidential matters of a very sensitive nature


Bachelor's Degree required.

License, Certification or Registration is required by law or regulation. (Y/N): N
Other certifications or registrations are required by the hospital. (Y/N): N


Experience in Healthcare setting preferred. Experience in healthcare infection control, clinical compliance, quality, risk or patient safety strongly preferred

EEO Statement
Brigham and Women's Faulkner Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to an employee's protected status, such as age, race, sex, color, ancestry, religion, national origin, physical or mental disability, veteran status, citizenship, gender identity or expression or sexual orientation.

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