Chief Quality and Patient Safety
$ 203,322 - $ 225,700 / month
Checking job availability...
Original
Simplified
- Provides executive leadership and direct supervision for staff assigned to Risk Management, Veteran Affairs Surgical Quality Improvement Program (VASQIP), Utilization Management, Tumor Registry, Patient Safety, Performance Improvement, and Systems Redesign
- Works towards achievement of high quality, safe, and cost effective evidence-based outcomes on a continual journey of a high reliability organization
- Collaborates with both administrative and clinical services to monitor quality and safety within the health care system
- Responsible for the facility's performance improvement and quality program which establishes, maintains, and monitors standards for the delivery of patient care and ensures fulfillment of the mission of the facility
- Participates with the executive leadership team as well as other management staff to address an organizational approach in assessing the environment, forecasting trends, transmitting values, communicating ideas, developing and implementing standards and policies, initiating programs and systems and management of care and resources
- Functions as facilitator in implementing action plans and process improvement strategies at service and medical center levels for follow-up to include regular progress reports
- Reviews Performance Measures, EPRP, VASQIP data, IPEC, and other quality data for trends and early intervention
- Applies clinical performance improvement methods, collects outcome data related to policy, procedure, and regulatory compliance. In collaboration with management, the Chief initiates performance improvement and system redesign projects
- Utilizes data and comparative analytical processes in recommending design and implementation of innovative programs to improve service excellence, customer satisfaction, and compliance with patient care and regulatory standards
- Actively participates in overall planning and management activities at the senior management level within the PVAHCS
- Assists management in top-level decision making concerning short and long range strategic planning, policy setting and daily operations; serves as the facility liaison to the VISN Quality Management Office
- Provides for continual planning to meet accreditation standards and oversight body guidelines on an on-going basis
- Coordinates facility activities related to Joint Commission standards including survey process preparation and any follow-up
- Coordinates the Office of Inspector General survey process preparation and follow-up, with the Commission on the Accreditation of Rehabilitation Facilities (CARF) survey process preparation and follow-up, as well as other surveys including but not limited to surveys from VA Central Office, the Office of the Medical Inspector, and the College of American Pathologists (CAP)
- Coordinates the facility systems redesign programs, the facility patient safety program, utilization management program, and the risk management program
- Provides leadership and direction in the development and implementation of systems to continually assess and improve the medical center's performance relative to the VHA Performance Measure
- Responsible for all hospital accreditation and oversight of surveys
- Interfaces with all VA regulatory agencies
- DNP or PhD preferred.
- 3 years of progressive leadership experience as a senior nurse leader with clinical and administrative oversight for a full range of areas (including inpatient, outpatient care ). . Administrative/Process improvement experience and exposure to VISN/National partnership forums/collaboratives/committees.
- 5 years Quality, Safety, and Improvement Experience
- Current certification as a Nurse Executive Board Certification (NE-BC) or Nurse Executive, Advanced Board Certification(NEA-BC)
- CPHQ Certification
Requirements
Conditions of Employment
- U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- 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.
- Selective Service Registration is required for males born after 12/31/1959.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- Must pass pre-employment physical examination.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
Qualifications
Basic Requirements:
The following Scope, Education and Dimension criteria must be met to qualify for Nurse V:
Reference: For more information on this qualification standard, please visit .
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.
- 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 () or The Commission on Collegiate Nursing Education (); 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 ().
- 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.)
The following Scope, Education and Dimension criteria must be met to qualify for Nurse V:
- Scope: Practice of an executive nature, comprised of complex leadership and administrative components, associated with critical health care issues and activities that drive meeting the organizational mission, health care and policy.
- Education: Master's degree in Nursing (MSN) and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR Master's degree in a *related field with a BSN and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in Nursing and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral 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 IV and meets all dimension requirements for Nurse V. *Note: Foreign education programs/degrees are not creditable as related degrees.
- Dimension Requirements:
- Leadership. Establishes the strategic direction for health care delivery, evidence-based practices, industry-leading research, and innovative care models. Creates a shared vision and successfully leads change to improve performance and attain measurable outcomes at the organization or enterprise level.
- Business Acumen. Transforms health care through the application of new processes, technology, informatics, data analytics, business principles, systems thinking and resource management at the organization or enterprise level.
- Inspiring an Industry-Leading Culture. Establishes an industry leading, shared decision-making culture; a diverse and inclusive workforce that serves Veterans, families, and caregivers of all backgrounds; builds trust and cultural competencies and catalyzes dynamic teams at the organization and enterprise level.
- Communication and Relationship Management. Drives the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional and organizational values, beliefs, and practices at the organizational or enterprise level.
- Professional and Social Responsibility. Sets the standard for a culture of holistic care, health advocacy and health equity. Applies ethical principles in decision-making at the organization or enterprise level. Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans, the community, and the health care industry.
Reference: For more information on this qualification standard, please visit .
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: . 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: .
Additional information
This job opportunity announcement may be used to fill additional vacancies.
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.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit at .
- Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. .
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
Conditions of Employment
- U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- 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.
- Selective Service Registration is required for males born after 12/31/1959.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- Must pass pre-employment physical examination.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
Qualifications
Basic Requirements:
The following Scope, Education and Dimension criteria must be met to qualify for Nurse V:
Reference: For more information on this qualification standard, please visit .
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.
- 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 () or The Commission on Collegiate Nursing Education (); 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 ().
- 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.)
The following Scope, Education and Dimension criteria must be met to qualify for Nurse V:
- Scope: Practice of an executive nature, comprised of complex leadership and administrative components, associated with critical health care issues and activities that drive meeting the organizational mission, health care and policy.
- Education: Master's degree in Nursing (MSN) and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR Master's degree in a *related field with a BSN and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in Nursing and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral 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 IV and meets all dimension requirements for Nurse V. *Note: Foreign education programs/degrees are not creditable as related degrees.
- Dimension Requirements:
- Leadership. Establishes the strategic direction for health care delivery, evidence-based practices, industry-leading research, and innovative care models. Creates a shared vision and successfully leads change to improve performance and attain measurable outcomes at the organization or enterprise level.
- Business Acumen. Transforms health care through the application of new processes, technology, informatics, data analytics, business principles, systems thinking and resource management at the organization or enterprise level.
- Inspiring an Industry-Leading Culture. Establishes an industry leading, shared decision-making culture; a diverse and inclusive workforce that serves Veterans, families, and caregivers of all backgrounds; builds trust and cultural competencies and catalyzes dynamic teams at the organization and enterprise level.
- Communication and Relationship Management. Drives the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional and organizational values, beliefs, and practices at the organizational or enterprise level.
- Professional and Social Responsibility. Sets the standard for a culture of holistic care, health advocacy and health equity. Applies ethical principles in decision-making at the organization or enterprise level. Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans, the community, and the health care industry.
Reference: For more information on this qualification standard, please visit .
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: . 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: .
Additional information
This job opportunity announcement may be used to fill additional vacancies.
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.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit at .