Summary

As part of the Senior Leadership team for the Medical Center - the Registered Nurse - Chief of Quality provides leadership - oversight - direction and development in performance improvement - utilization review - risk management - patient safety - data management - strategic and operational planning - and performance management processes throughout the Medical Center. They function in a leadership role - assisting and supporting the Director in accomplishing the goals of the Medical Center.

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
• The following Scope - Education and Dimension criteria must be met to qualify for Nurse IV: Scope: Executes leadership that is characterized by substantial and continuous responsibility and accountability for population groups or integrated programs that cross service and/or discipline lines and influence organizational mission and health care
• Education: Master's degree in Nursing (MSN) and 4 years of professional nursing experience - one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV
• OR Master's degree in a *related field with a BSN and 4 years of professional nursing experience - one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV
• OR a Doctoral degree in nursing and 3 years of professional nursing experience - one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV
• OR a Doctoral degree in a *related field with a BSN and 3 years of professional nursing experience - one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Dimensions: Leadership
• Leads health care delivery by leveraging evidence-based practices - industry-leading research - and innovative care models
• Drives a shared vision and successfully leads change to improve performance and attain measurable outcomes at the program or service level
• Business Acumen
• Transforms health care by implementing new processes - technology - informatics - and data analytics using business models and fundamental concepts of resource management at the program or service level
• Inspiring an Industry-Leading Lifestyle
• Employs an industry leading - shared decision-making lifestyle
• Cultivates a workforce that serves Veterans - families and caregivers of all backgrounds and builds trust - lifestyle competencies and catalyzes dynamic teams at the program or service level
• Communication and Relationship Management
• Directs the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional organizational values - beliefs and practices at the program or services level
• Professional and Social Responsibility
• Operationalizes a lifestyle of holistic care - health advocacy and health equity
• Applies ethical principles in decision-making at the program or service level
• Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans and the community
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service.

Duties

• The RN - Chief of Quality provides administrative oversight and executive leadership and accountability for the Performance Improvement Management Service programs and processes at the Syracuse VAMC
• The incumbent is a professional registered nurse who works collaboratively with leaders of other departments - services - programs - and executive leadership to strategically plan - implement - monitor - evaluate - and improve care - as well as meet operational goals of the Medical Center - VISN 2 and Central Office
• They will demonstrate a practice of an executive nature - comprised of complex leadership and administrative components - associated with critical health care issues and activities that influence organizational mission - healthcare - and policy
• The RN - Chief of Quality has overall responsibility and administrative oversight and direction for the facility wide programs listed below including ensuring integration of these programs into the facility's Performance Improvement Program to improve care - reduce risk to patients and staff and to foster a culture of safety in the organization: Accreditation/Continuous Readiness Review Programs: The Chief of Quality is responsible for ensuring the V ASDHS has systems in place for accomplishing successful surveys or reviews by The Joint Commission (TJC) that include Hospital - Behavioral Health - Home Care and Nursing Care Centers programs and other regulatory agencies internal/external to the organization - such OIG-CAP and the Long Term Care Institute (LTCI)
• The Chief of Quality ensures the PIMS staff provides continuing education and training to all employees regarding the standards/requirements of these accrediting/regulatory agencies
• Patient Safety (PS) Program: The Chief of Quality is responsible for the oversight and implementation of an effective PS Program that promotes a culture of safety throughout the organization
• This program is designed to assess - monitor and evaluate organizational compliance with professional standards of practice - TJC National Patient Safety Goals and standards - the VHA National Center for Patient Safety requirements and applicable regulatory agency standards
• Protected Peer Review Program: The Chief of Quality is responsible for the oversight and implementation of an effective Protected Peer Review Program in compliance with the VHA Protected Peer Review Directive /including overseeing the duties and responsibilities of the facility Peer Review Coordinator
• Risk Management (RM) Program: The Chief of Quality is responsible for the oversight and implementation of an effective RM Program designed to minimize the probability of adverse risk to patients - staff and visitors
• The RM program assists in protecting the assets of the facility and prevents loss by accurately identifying - reporting - tending - reviewing - and correcting problems leading to incidents through risk identification and analysis
• External Peer Review Program (EPRP): The Chief of Quality is responsible for the oversight and implementation of the EPRP and maintains positive relationships with the EPRP organization - the West Virginia Medical Institute (WVMI) - to ensure timely completion and submission of EPRP reviews
• Utilization Management (UM): The Chief of Quality is responsible for the oversight and implementation of an effective Utilization Management Program
• This includes overseeing the duties and responsibilities of the facility Utilization Management Staff under Quality Management Service
• Data Management: The Chief of Quality is responsible for the oversight and implementation of an effective Data Management Program
• This includes overseeing the duties and responsibilities of the facility Data Management Staff under Quality Management Service
• Process Improvement: The Chief of Quality is responsible for the oversight and implementation of an effective Process Improvement Management Program
• This includes overseeing the duties and responsibilities of the facility Lean/Six Sigma/Process Improvement Program under Quality Management Service
• The Chief of Quality functions as an administrator - leader - educator - and consultant applying management theory in collaboration with other services
• Additional duties as assigned 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 - 7:30am-4:00pm Telework: Not Available Virtual: This is not a virtual position Relocation Incentive: May be Authorized