Veterans Affairs, Veterans Health Administration Registered Nurse - Quality Management Program Director in Houston, Texas
Summary The Quality Manager Program Director is responsible for the ongoing development of QSV program which ensures facility compliance with standards and internal performance expectations, as delineated in VHA guidelines and directives. Coordinates and oversees the QSV program for the Michael E. DeBakey VA Medical Center. Responsibilities The Quality Management Program Director will provide guidance within an enterprise risk management framework, driving improvement and developing processes which support safe and efficient patient care delivery. Achievement of these responsibilities will require strong skills in: the leading of both large and small interdisciplinary groups seeking system systems improvement outcomes, teaching, writing, chart review, data extraction, evaluation and trending, electronic data reporting, including development of spreadsheets, tables and graphs, project management skills, presentation development, priority-setting, and critical thinking skills. The Quality Management Program Director functions as a Manager over QM staff and all aspects of the QM program to include, but not limited to Accreditations and associated preparation, regulatory bodies, and National Patient Safety Goals. The incumbent is responsible for demonstrating leadership, collegiality, collaboration and creative approaches to the execution of quality management and accreditation activities, and continual regulatory compliance readiness, patient safety and investigation activities. The Quality Management Program Director has the responsibility for planning and coordinating continual regulatory compliance readiness activities throughout the Medical Center and Community Based Outpatient Clinics (CBOCs). He/she works with peers/individuals/services to proactively prepare and obtain the information necessary for TJC, Inspector General (IG) and other accreditation/validation regulatory compliances. The QSV Program Director is responsible for translating standards, policies, directives, theories, and strategies into action within the complex interrelationships that exist related to external accreditation/review. The Quality Management Program Director prepares and presents QM information and data to identified MEDVAMC Committees as required and requested. Ensures a process for communicating all QM data within the facility and VISN as a component of the Quality Management and Systems Redesign systems. Supervises staff to ensure continuity of Quality reviews. The Quality Management Program Director is responsible for continuous readiness of Patient Care Service for accreditation and regulatory agency review and compliance (Joint Commission, Inspector General, etc.); performance and quality measures; and program monitors and actions (Patient Family Centered Care [PFCC] and the CAT Team). Manages processes related to survey readiness, IPEC monitors, review of SAIL data and EPRP data, tracers, chart reviews, and environment of care surveillance. Compiles data and communicates information to QSV leadership in a format that is conducive for utilization in decision making, strategic planning and performance improvement. Rounds frequently to work with staff at the unit-level on accreditation readiness issues. Troubleshoots issues related to quality of care and provides real time feedback to nursing leadership. The Quality Management Program Director serves as a key member of and may lead multi-disciplinary project teams related to continuous readiness with facility, VISN 16, and/or VHA field staff, and supports key stakeholder meetings and conferences. Responsibilities may include: preparation of team charters, task breakdown, timelines, milestones, identification of special conditions and constraints, quality assurance, configuration management, and project deliverables; completion of necessary documentation to monitor and track project accomplishments and resource Quality; maintenance of effective communications between management, project members, partners, and customers; ensuring that project deliverables meet defined functional and technical specifications; conducting post-project evaluations. The Quality Management Program Director requires flexibility in schedule and assignments, as this is a 24/7 hospital. The incumbent must be poised and articulate in communicating with people of varied educational levels and varied ethnic backgrounds. Willing to work cooperatively as a member of a team in all assignments. Makes caring for the veteran his/her priority while in the work setting and demonstrates customer service principles in all aspects of work. Self motivated in the pursuit of meeting professional work standards. Basic Life Support (BLS) required for RNs in direct patient care positions. Advanced Cardiac Life Support (ACLS) required in specific specialty areas. Work Schedule: Monday - Friday 7:30am - 4:00pm (Shift Work) Compressed/Flexible: No Telework: Not available Virtual: This is not a virtual position. Functional Statement #: RN QM Program Director Financial Discloser Report: Not required Requirements Conditions of Employment Qualifications Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Preferred Experience: Bachelor's in Nursing; 2 years of experience in Quality Management; Preferred candidate should maintain certifications such as HCQM, CPHQ, CPHRM, etc. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: This position requires potentially long periods of continued walking, standing, and sitting. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs. Must complete annual Employee Health requirements, such as annual TB screening or testing, as a condition of employment. In the performance of duties, the incumbent may be required to drive and/or ride in GSA-vehicles. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Additional Information Testing Designated Position: All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period. This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.