RN Quality Consultant-QM
1. Uses clinical knowledge to evaluate the quality and effectiveness of clinical performance within the facility, using data collected by internal and external monitoring processes. Relays this information to clinical leadership and senior leaders.
2. Uses clinical knowledge to provide day-to-day evaluation of situations which might not meet accreditation and VHA standards, implementing strategies to develop performance improvement plans. Promotes sustainability of said plans.
3. Uses clinical knowledge to complete individual quality reviews and/or case assessments to determine which improvement efforts are necessary to improve care delivery. Implements relevant improvement strategies, which may include, but are not limited to, one-on-one teaching, group educational sessions, and process redesign, and /or review.
4. Possesses a thorough working knowledge of the directives, policies, and performance standards of the Veterans Health Administration (VHA) arm of the Department of Veterans Affairs.
5. Possesses a thorough working knowledge of The Joint Commission and other oversight agency standards, such as the Commission on Accreditation of Rehabilitation Facilities (CARF), Long Term Care Institute (LTCI), the Office of the VA Inspector General and its Combined Assessment Program (OIG-CAP), and a host of other accrediting agencies as they relate to the enterprise risk-management framework.
6. Utilizes knowledge of medical terminology, anatomy, physiology, medical and nursing diagnoses, reading and interpreting orders, lab values, progress notes, medications, and treatment plans, to be able to determine and discuss the appropriateness of health care provided by various health care professionals at VANCHCS.
7. Responsible for translating theories, strategies, and national policies into action within the complex interrelationships that exist related to continuous readiness.
8. Leads, directs, and assists healthcare system staff in the preparation and successful completion of external accreditation surveys.
9. Sits on various health care system committees as mandated by VHA and/or local policy.
Chairs committees or ad hoc groups aimed at accreditation preparation, continuous readiness, and/or meeting facility performance standards.
10. Works with staff throughout the healthcare system to develop corrective action plans which address deficiencies in practice and opportunities for improvement.
11. Serves as accreditation liaison with The Joint Commission, Office of Inspector General (OIG), Long Term Care Institute (LTCI), the Commission on Accreditation of Rehabilitation Facilities (CARF), and a host of other accrediting agencies as assigned.
12. Completes other assignments as delegated by the Chief of Quality Management and/or Director of Accreditation, Risk Management, and Patient Safety or the Medical Center Director.
1. Provides accurate and timely continuous readiness tracking reports and action plans to the Chief of Quality Management and/or Director of Accreditation, Risk Management, and Patient Safety under the Quality Management Service, the Medical Center Director, the Senior Leadership team, facility service chiefs, and VISN 21 Quality Management staff as appropriate.
2. Responsible for maintaining clear communication between the facility and national work groups, participating in national conference calls and communicating relevant opportunities for improvement and lessons learned, including issues which have potential impact beyond the local level.
3. Plays a critical support role in developing and coordinating internal review systems to assure that both clinical and administrative activities are in compliance with agency accrediting and regulatory requirements.
4. Assists the Chief of Quality Management and Director of Accreditation, Risk Management, and Patient Safety, Quality Management Service, the Medical Center Director, and Senior Leadership in the development or improvement of policies that will ultimately determine whether we meet external and internal performance standards.
5. Analyzes data, identifies trends and concerns. Prepares analyzed data and makes recommendations for improvement. Leads ad hoc groups to drive such improvement.
Work Schedule: Monday- Friday with the possibility of a compressed schedule between the hours of 7:00-5:30.
Working at least nine days per pay period
Financial Disclosure Report: Not RequiredBasic Requirements:
- United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- 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.
1. 5 years of experience as a Registered Nurse
2. Master's degree in nursing or related field
3. Certification as a Clinical Nurse Specialist or a Clinical Nurse Leader
4. Certified Professional in Healthcare Quality (CPHQ)
5. Certified Joint Commission Professional (CJCP)
6. Experience with the Commission on Accreditation of Rehabilitation Facilities (CARF) standards
7. Prior experience in Quality Management or Systems Redesign
8. Extensive experience with accreditation and/or regulatory compliance
9. Certification in lean management (green belt or black belt training)
10. Prior experience in teaching (as a faculty member at a college or university)
11. Strong writing and communication skills
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.
Selected applicants will be required to complete an online onboarding process.
To apply for this position, you must provide a complete Application Package which includes:
RN application VA Form 10-2850a
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. Required at time of application.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, etc.
- Cover Letter
- Executive Core Qualifications (ECQs)