Summary

The Central Texas VA Health Care System is recruiting for a Performance Measures Coordinator Registered Nurse position. The incumbent leads quality improvement and performance measurement initiatives - collects and analyzes data - monitors compliance with policies and standards - identifies trends - supports evidence-based practice - collaborates with interdisciplinary teams - and promotes continuous improvement in patient care and organizational performance.

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
• Preferred Experience: High performer - who functions independently and can navigate effectively within complex health care system
• 1 year experience in analyzing hospital performance metrics (SAIL - EPRP - eQM - SHEP - VSignals)
• 1 year experience in leading multidisciplinary team/committee to facilitate process improvement
• Lean Six Sigma Green or Black Belt Certified
• Experience in driving process improvement through data analysis and LEAN methodologies
• 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/12984025
• 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/
• Physical Requirements: Light lifting under 15 pounds
• light carrying under 15 pounds
• reaching above the shoulders - use of fingers - walking 1-2 hours - standing 1-2 hours - both legs required - far vision correctable in one eye to 20/20 and to 20/40 in the other - both eyes required - ability to distinguish basic colors - hearing aid permitted
• may be exposed to infected patients and contaminated equipment
• may be expected to don protective equipment
• may be exposed to combative patients
• must complete annual Employee Health requirement.

Duties

• The Performance Measures Coordinator is a fully developed position that executes continuous improvement responsibilities that demonstrate leadership - experience - and creative approaches to management of complex patient care
• Facilitates the planning - monitoring - coordinating - and administrating recommendations for clinical and administrative Performance Measures (e.g
• ORYX - Healthcare Effectiveness Data and Information Set (HEDIS) - Patient Experiences - External Peer Review Program (EPRP) - Electronic Quality Measures (eQM) - Strategic Analytics for Learning and Improvement (SAIL)
• Provides direct support to Service Chiefs - Product Line Managers - and others in planning - designing - integrating - implementing - modifying - and evaluating the effectiveness of services to improve the performance measures and monitors
• Provides real-time monitoring of all inpatients (acute - ICU - and surgical care) monitors and measures - Ambulatory Care (Primary Care - Specialty Care - Emergency Department) - and Long Term / Residential Care (CLC - Domiciliary Programs)
• Actively functions as facilitator on Process Action Teams and Work Groups
• Provides real-time - reliable - and accurate feedback and education to clinical leadership and clinical staff on findings of real-time monitoring
• Reports performance measure issues to the leadership - Chief of Staff - and top-level management
• Will be the facility's key person to help develop the medical center response in identifying performance measure improvement
• identifies system problems and develops and implements appropriate interventions
• Coordinates the EPRP activities including review of variances - analysis of results related to processes - and EPRP Exit Interviews
• Possesses a thorough knowledge of the Office of Quality Performance (OQP) Measure Technical Manual
• Provides education to all levels of the organization - especially to leadership - Service Chiefs - and champions on the performance measure process
• Provides on-going education to clinical services and staff on the EPRP process - measures - and monitors outcomes at all CTVHCS sites
• Coordinates and facilitates the Performance Measures Oversight Committee (PMOC)
• Supports and provides backup for the External Peer Review Program (EPRP)
• Support for EPRP includes attending and presenting on EPRP process - real-time monitoring - clinical dashboards - and outcomes at monthly Performance Measures Oversight Committee (PMOC) meetings and as needed in other meetings
• Recommends champions for each performance measure and performance monitor - including supporting indicators
• Disperses EPRP Data Accountability Checklists (DAC) to designated Service Chiefs and champions (e-mail encrypted or hard copies) - on the EPRP process as soon as information is available to access on WVMI
• Collects and organizes DAC appeals from Chiefs and champions prior to the EPRP exit
• Coordinate with abstractor for review prior to the Exit Review date (minimum of one day prior)
• Submits the appeal spreadsheet to the ELB before the date of the EPRP Exit - if requested
• Reviews EPRP Abstractor feedback with Chiefs and champions in order to conduct a second-level review of fallouts
• Presents a preliminary DAC report to leadership upon request
• Schedules and facilitates meetings between the EPRP Abstractor and Chiefs and champions as needed
• Reviews potential appeals with VISN 17 Performance Measure staff prior to and immediately after EPRP Exit
• Submits West Virginia Medical Institute(WVMI) and Office of Quality Performance(OQP) appeals immediately after evaluating feedback from VISN 17 Performance Measure staff
• Proactively follows the appeal process and provides status and disposition updates to affected Chiefs and champions
• Ensures the Abstractor has adequate technical and space resources prior to the arrival of the Abstractor
• Performs other duties as directed
• The Performance Measures Coordinator will provide an EPRP briefing at the morning report upon request
• 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 - 7:30 a.m
• - 4:00 p.m
• Telework: Position is eligible for Ad-Hoc Telework
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required