Director, Environmental Health and Safety

Pay range: $121,472 - $182,187/year

Relocation Bonus available for this position.

This position comes with a comprehensive benefits package that includes medical, dental, vision, a 403(b) retirement plan, and a generous Earned Time Off (ETO) package.

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Director of Environmental Health & Safety

REPORTS TO POSITION: VP Chief Nursing Executive

DEPARTMENT: Environmental Health and Safety

DATE LAST REVIEWED: July 2024

OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENT SUMMARY:

The Environmental Health & Safety Department is dedicated to ensuring the safety, health, and well-being of all patients, caregivers, and visitors. The Department is responsible for developing, implementing, and maintaining comprehensive programs that encompass environmental health, occupational safety, infection prevention, emergency preparedness, and regulatory compliance.

POSITION OVERVIEW:

The Director of Environmental Health & Safety is responsible for developing, implementing, and overseeing comprehensive safety and infection control programs to ensure a safe and healthy environment for patients, caregivers, and visitors. This role includes managing all aspects of environmental health and safety, infection prevention and control, regulatory compliance, and emergency preparedness for St. Charles Health System (4 hospital campuses and ambulatory clinics). This position directly manages assigned caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

1. Manages the Environment of Care, Safety, and Infection control programs for St. Charles Health System to ensure patient, visitor, and caregiver safety with adherence to all federal and state rules and regulations.
2. Develops program goals and objectives to ensure the EOC, Safety, and Infection Control programs are aligned with best practices and supports the health system’s True North strategy, mission, and vision.
3. Manages data collection, analysis and reporting for all Environment of Care programs. Presents data to caregivers, leaders, and executives to inform teams of safety hazards and progress towards mitigation.
4. Maintains policy, staff training, and educational content related to hazardous materials and waste for the system.
5. Manages Environment of Care rounds at all St. Charles Health System campuses/ambulatory clinic buildings. Maintains a schedule to ensure rounds are conducted twice per year in all areas where patients are served and once per year in areas where patients are not served. Ensures that leaders are aware and supported for addressing gaps in EOC rounds.
6. Coordinates and monitors improvement activities related to the Environment of Care. Conducts regular risk assessments, develops action plans, and evaluates effectiveness. Provides system leadership updates on the EOC program and improvement activities to address gaps.
7. Collaborates with Materials Management and Bio-Med departments to manage the product recall process.
8. Collaborates with Facilities, Caregiver Health, Infection Prevention, Supply Chain, and other key departments to ensure EOC and safety standards are implemented, trained to, and followed.
9. Performs safety related training to leadership teams as well as front line caregivers as requested, including general hazard awareness, specific use of personal protective equipment and fire response.
10. Coordinates and monitors Hazardous Materials Management programs such as the OSHA Hazcom Standard, Medical Waste Disposal, Spill Response Plans and Hazardous Waste Generation in compliance with Federal, State and Local regulations. Maintains Safety Data Sheet database for all St. Charles Health System facilities.
11. Performs the safety components of the Pre-Construction Risk Assessment (PCRA) for all construction and renovation projects. Monitors compliance with Interim Life Safety Measures (ILSM) and serves as a resource for staff training when construction projects create building safety deficiencies.
12. Oversees fire and life safety processes in partnership with facilities including coordination of fire drills, equipment inspections (extinguishers, strobes, alarms, etc.), training and post incident debriefs. Monitors life safety preventative maintenance activities for compliance.
13. Collaborates with Bio-Medical Services team to ensure medical equipment is inspected, tested, and maintained for safe patient & caregiver use.
14. Monitors all facilities for compliance with Joint Commission / OSHA / NFPA and other regulatory standards. Escalates concerns to the Chief Nurse Executive and campus leadership.
15. Develops and manages the safety components of contractor safety training, including the “Above Ceiling Work Permit,” PECOs, ILSM. Monitors for compliance with the measures that are implemented.
16. Collaborates with Facilities Managers on all aspects of the EOC plan that affect the physical plant. Coordinates utility management activities through their involvement with the EOC Committee.
17. Oversee the development, implementation, and evaluation of infection prevention and control programs.
18. Accountable for reporting compliance with the standard surveillance definitions of the Centers for Medicare and Medicaid Services (CMS), state and local reporting agencies, the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN).
19. Responsible for ensuring an effective communication and working relationship with the local and state Public Health departments.
20. Partners with the Infection Prevention Medical Director to evaluate evidence-based caregiver and provider infection prevention and control practices and promote improvement activities and standards of care for optimal patient outcomes.
21. Oversees infection control environment of care rounds compliance with TJC, CMS, DPH, CDC including, quality review documentation of water, air quality and surface testing in special areas.
22. Oversees the need for, develops and implements written policies and procedures for infection prevention and control, including those for standard precautions and for transmission-based precautions.
23. Develops and monitors activities related to continuous quality assessment and improvement, serving as a consultant, facilitator, educator, and resource for the organization relating to evidence-based practice infection prevention.
24. Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.
25. Hires, directs, coaches and monitors the performance of all direct reports, to develop and maintain a high-performance team that meets organizational and department goals.
26. Monitors and ensures all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals.
27. Provides and oversees team’s delivery of customer service in a manner that promotes goodwill, is timely, efficient and accurate.
28. Supports the vision, mission and values of the organization in all respects.
29. Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
30. Provides and maintains a safe environment for caregivers, patients and guests.
31. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner.
32. May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:

Required: Bachelor’s degree in related field.
Preferred: Master’s degree in healthcare related field.

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Certification as Healthcare Environmental Manager (HEM). Environmental Protection Agency (EPA) Resource Conservation and Recovery Act (RCRA) Hazardous Waste Management training, for the state of Oregon. Department of Transportation (D.O.T.) Hazardous Materials Ground Shipping certification training. DOT and EPA/RCRA certification trainings must be obtained within 120 days of placement in the department.
Preferred: Certified Safety Professional (CSP).

EXPERIENCE:

Required: Minimum seven (7) years’ experience in environmental health and safety and/or infection control in a healthcare environment. Knowledge of compiling and documenting safety related statistics. Background in safety audits both external (regulatory agencies) and internal. Minimum two (2) years of leadership experience.

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION:

Travel: Ability to travel to all St. Charles worksites.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.
Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation, operation of motor vehicle.
Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing, or pulling 1-10 pounds, grasping/squeezing.
Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing, or pulling 11-25 pounds, operation of a motor vehicle.
Never (0%): Climbing ladder/stepstool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

Schedule Weekly Hours:

40

Caregiver Type:

Regular

Shift:

First Shift (United States of America)

Is Exempt Position?

Yes

Job Family:

DIRECTOR