Summary

The Registered Nurse - Assistant Chief Quality Safety Improvement functions as a clinical expert and executes position responsibilities that demonstrate leadership - experience - and creative approaches to management of complex patient care. Assesses - plans - implements - and evaluates delivery of care based on age specific components. Demonstrates performance and leadership that is broad enough to improve the care for a group of patients.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (Reference VA Handbook 5005 - Appendix G6)
• OR In cases of graduates of foreign schools of professional nursing - possession of a current - full - active - and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12944098
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Preferred Experience: At least 3 years supervisory experience
• At least 4 years administrative experience
• Experience reading - interpreting - and analyzing The Joint Commission (TJC) or Office of Inspector General (OIG) Standards or other technical or administrative directives - polices and regulations
• Experience utilizing Performance Improvement methodologies
• Experience leading - planning and executing TJC - OIG - CARF - and/or other regulatory site visits
• Ability to use sound judgement in leading QM activities and actions for problem solving and decisions
• Ability to analyze complex and critical data and easily identify trends - issues of concerns - action needed to accomplish facility requirements
• Ability to be flexible - adaptable - and prioritize multiple tasks with competing deadlines
• Ability to effectively and positively work with others to achieve common goal
• Ability to maintain confidentiality with sensitive assignments and/or facility reports
• Organized and detailed oriented as required for data tracking and monitoring assignments
• Masters Prepared Nurse
• Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation - see Duties section for essential job duties of the position
• May require standing - lifting - carrying - sitting - stooping - bending - puling - and pushing
• May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment
• Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions
• the area is adequately lighted - heated - and ventilated
• However - the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations.

Duties

• Duties for this position include - but are not limited to: Supervises numerous assigned QSI staff (Quality Consultants/Specialist and Program Analyst - Accreditation Specialist - Peer Review Specialist - and Risk Management Specialist) - assesses plans - implements - coordinates - monitors and evaluates the quality and safety of the delivery of care for the organization
• Assumes a leadership role in facilitating regulatory compliance for internal and external oversight bodies (i.e. - The Joint Commission (TJC) - Commission on Accreditation of Rehabilitation Facilities (CARF) - Veterans Health Administration (VHA) Directives and Handbooks - etc.) - Occupational Safety and Health Administration (OSHA) - Office of the Medical Inspector (OMI) - Office of the Inspector General (OIG) - and VHA performance measures - supporting performance improvement work - and supporting and guiding the work of committees or governance structure
• Ensures that services have systems and processes in place to provide safe - quality care that is consistent with external benchmarks
• Leads performance improvement initiatives by identifying quality metrics - trending data - maintaining the QSI dashboards - and acts as a subject matter expert in data analysis and data display
• Consults and acts as a resource to leadership and staff in standards interpretation implementation - patient safety - risk management - peer review and re-design of processes and structures to improve care outcomes
• Develops and implements policy and procedures - collaborates with service departments - and works toward meeting the strategic plan of the organization
• Oversees the monitoring of corrective actions from survey findings and assists services who are performance outliers
• Provides oversight for programs such as Accreditation Tort Claims - Risk - and Peer Review Program processes
• Responsible for completing clinical quality reviews - clinical data analysis - and identifying opportunities for improvement
• Assists in policy-making activities as related to patient safety and quality of care as well as the overall functioning of administrative and clinical programs
• Collaborates with other health care staff or Interdisciplinary Teams (IDT) to establish and maintain programs that cross service and/or discipline lines and influence organizational mission and health care
• Demonstrates the knowledge and skills necessary to communicate and interact appropriately and courteously with all internal and external customers and to maintain confidentiality of patient/employee information electronically - verbally - and written
• Collaborates with the Accreditation Coordinator for the coordination of accreditation readiness activities focused on standards compliance - education of staff on standards - VHA requirements - and customer satisfaction for internal and external stakeholders
• Influences care outcomes by collaborating with members of numerous interdisciplinary teams
• Leads QSI staff through performance evaluations - promotes and supports High Reliability Organizational (HRO) principles and activities for cultural changes - and change management principles
• 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 - Friday - 8:00am - 4:30pm - subject to change based on the needs of the facility
• Telework: Not Available
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: May Be Authorized
• Permanent Change of Station (PCS): Not Authorized.