The incumbent is responsible for the following: trending and analyzing data, interpreting Joint Commission and other external agency standards, interpreting VHA handbooks and directives regarding quality management/performance improvement/patient safety issues; collaborating with the facility Patient Safety Officer; collaborating and assisting in system redesign processes and monitoring progress of reviews and follow-action items to ensure completion in a timely manner.
The incumbent is responsible for coordinating and maintaining a comprehensive, organized, continuous readiness program to review and identify opportunities for improvement in order to achieve excellence in the delivery of healthcare. Assists in developing Quality Improvement processes to assure that all required information is procured and acted upon to meet the expectations of the facility, Joint Commission, VHA Headquarters, Office of the Medical Inspector, Office of Inspector General or other external organizations. Responsible for all directives and standards relating to the Quality Management program for areas within assigned responsibility.
The incumbent will assist the Service Line and ensure performance improvement processes are in place, follow-up is conducted, and outcome reported. When required, he/she conducts reviews to evaluate compliance with program regulations, policies and procedures and assists with the development of facility policies and procedures as appropriate. Assists in develop Quality Improvement approaches for standardizing system related procedures to minimize variation. Supports facility activities in the coordination and development of data collection and analysis techniques, primarily in the areas of specific Performance Measures and Performance Improvement indicators.
Incumbent is knowledgeable of Performance Improvement principles; statistical processes including trend and comparative analyses and has the expertise to make recommendations based on findings. Reviews all performance improvement data for assigned areas and assists responsible staff in initiating/facilitating appropriate action based on VA guidance documents. Facilitates education of personnel, both in the facility orientation of employees on performance improvement and in specific training for those involved in the performance improvement activities within services, on hospital Quality Improvement committees and/or within process action teams.
The incumbent conducts various patient care studies based on areas assigned, including review of patient incident report reviews, utilization management reviews, medical record reviews for evidence of required documentation as well as the quality and level of care provided. Provides clinical expertise and consultation to assist in data driven decision making and performance improvement matters. Conducts tracers, operational assessments and participates in the design of special studies to define the cause and scope of issues or trends and assists in the identification of appropriate criteria for problem resolution. Analysis includes trend, pattern and other statistically valid techniques to assist in focusing program attention and efforts. Participates in the development of innovative approaches to the establishment, enhancement, modification, and/or improvements in a variety of facility programs related to performance improvement/quality management. Reviews service/section/committee meetings for results of assessment and improvement activities including conclusions, recommendations, actions and evaluations. Closely monitors and advises services and committees of Quality Improvement topics that need to be addressed at meetings in order to meet The Joint Commission standards compliance.
Functions as an advanced clinician and executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex patient care. Performs other duties as assigned to meet the needs of the Quality and Patient Safety Service, Veterans, and the organization.
VA offers a comprehensive total rewards package: VA Nurse Total Rewards
Pay: Competitive salary, regular salary increases, potential for performance awards
Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Licensure: 1 full and unrestricted license from any US State or territory
Work Schedule: Monday thru Friday - 8 hour tour between 7:30am to 5:00pm
Telework: Not Authorized
Virtual: This is not a virtual position
Recruitment/Relocation Incentive: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Starting at $77,902 Per Year (VN 00)
