Works with leaders for continuous survey readiness. (The Joint Commission, Inspector General, CARF, etc) performance and Quality measures. Manages process related to survey readiness and standards compliance, including data, tracers, chart reviews, and environment of care surveillance. Duties and responsibilities to include but not limited to: Provides leadership and coordination for VISN and Facility Performance Measures and Clinical Practice Guidelines Indicators. Monitors the follow-up to recommendations specific to risk resulting from the Joint Commission (TJC) and other accreditation and external review visits. Interprets rules and regulations and has a broad knowledge of VA regulations, TJC, and other applicable federal and investigatory requirements to provide accurate information for management, chief of services, other officials and staff. Ability to plan, organize and direct team study work root cause analysis (RCA) teams, process improvement teams, and Healthcare Failure Mode and Effects Analysis (HFMEA) teams, aggregate review teams, or focus review teams. Attends VISN/ national work groups and conferences pertaining to his/her duties as directed by the Director of Quality and Safety. Partners with Service lines and leaders related to Quality education, training, and process improvement Mentors all staff in Quality practice, processes, and outcomes Data collection, analyzing, trending, reporting, including sensitive indicators/vulnerabilities and best practices Partner with Patient Safety and HRO to support Just Culture and High Reliability processes and journey. Monitor compliance and assist with removing barriers and adding value to processes Prepare for survey Supports a culture of safety and accountability Work Schedule: Monday - Friday, 7:30AM - 4:00PM Financial Disclosure Report: Not required Pay: Competitive salary, regular salary increases. Paid Time Off: Annual leave at the rate of eight (8) hours per biweekly pay period; Sick leave at the rate of four (4) hours per biweekly pay period; 10 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. Recruitment Incentive/Relocation Incentive is not authorized for this position.
Internal Number: 600048800
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.