The primary purpose of the position is to serve as a coordinator and point of contact for policy management and external accreditation/review procedures and activities. Accrediting bodies and review groups include but are not limited to The Joint Commission (TJC), Office of Inspector General (OIG), VISN 19 Inspection Teams, Commission on Accreditation of Rehabilitation Facilities (CARF), and Ascellon.

Duties

Duties include, but are not limited to: Knowledge of current regulatory requirements and issues in healthcare and determines impact on ECHCS functions. Serves as the organization's trusted agent for external accreditation reviews, including follow-up, tracking, and auditing of corrective actions to closure. Provides direct staff assistance to the QPS Service in the coordination and preparation for various external surveys, audits and reviews. - Oversees ECHCS policy and governance structure management. Serves as an advisor to service chiefs/section chiefs/unit managers and ELT in the interpretation and application of accreditation, Veterans Health Administration (VHA), local and professional standards and guidelines (i.e., TJC standards and other regulatory standards, VHA Directives, etc.). Plans and coordinates assessments and evaluation of organizational continual compliance and implements strategies to promote ongoing mission readiness. Organizes and conducts periodic audits, assessments, and tracers. Ensures organizational documents submitted to external bodies are regulatory compliance ready. Employs evidence-based quality and performance improvement methodologies and strategies to facilitate continual compliance and optimal performance. Provides educational engagement during tracer rounds to service chiefs/section chiefs/unit managers and ELT to include materials and tools to promote staff understanding, compliance and continual mission readiness. Facilitates audits for the collection of substantiating evidence for action plans from service chiefs/section chiefs/unit managers and ELT to ensure sustainability of improved performance. Compiles and analyzes data and audits related to continual mission readiness, prepares reports and presents findings and recommendations to service chiefs/section chiefs/unit managers and ELT. Areas of concern are immediately brought to the attention of the QPS leadership. Serves on organizational governance structure groups as a confidential consultant to ensure processes support the internal security of the organization. Demonstrates competency in technological means of data management. Supports other QPS positions and programs based on service and organizational need, to include meeting service level expectations of supporting on-site survey activities. Manages VA ECHCS medical center policy (MCP) and document program in accordance with VA and VHA policy, National Archives and Records Administration (NARA), and other applicable Federal laws and regulations. Provides expert advice and guidance to senior leaders and management concerning organizational policies, plans, SOPs and other published documents. Establishes and promotes organization wide policy and document management procedures. Responsible for managing all facility policy, plan, SOP, and other document rescission requests. Develop organization specific MCP, plan, SOP and other document training materials as needed, and provide training within the facility to staff, employees, students, contractors, and volunteers. 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 Cente red Care [PFCC] and the CAT Team). Responsible for fostering continuous mission readiness for accreditation and regulatory agency review and compliance (TJC, OIG, CARF, etc.) and supporting performance and quality measures improvements. Work Schedule: Mon-Fri 8-4:30 Telework: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Virtual: This is not a virtual position. Position Description/PD#: Health System Specialist-Regulatory Compliance Coordinator/PD141770 Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not approved Permanent Change of Station (PCS): Not authorized. Financial Disclosure Report: Not required

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 09/08/2023. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-12 position you must have served 52 weeks at the GS-11. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. You may qualify based on your experience and/or education as described below: Health System Administration Series, 0671 Individual Occupational Requirements: Undergraduate and Graduate Education: Major study -- hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration. or Specialized Experience Progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following: Missions, organizations, programs, and requirements of health care delivery systems; Regulations and standards of various regulatory and credentialing groups; and Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. Or Special Provision for In service Placement: Successful completion of an agency-sponsored on-the-job training program may be substituted for qualifying experience, provided it included a formal individualized training plan. Such a training program must have been conducted in an operating health care system and included: Assignments providing a knowledge of basic health system administration philosophies, practices, and procedures, and basic government administrative policies and requirements; Practical assignments providing an opportunity to apply health system administration skills and principles (as the individual progresses, work assignments must be characteristic of the grade level to which he or she is assigned); and Oversight by an experienced health system administrator with periodic evaluation of the individual's progress and appropriate adjustment of the training program. In addition to meeting the IOR you must also meet: Specialized Experience GS-12: You must have one year of specialized experience equivalent to at least the next lower grade GS-11 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Serves services/sections/units and senior level management through policy management and external accreditation/review procedures and activities; Executes quality management and continuous accreditation/regulatory compliance readiness activities including tracking, trending, and auditing for the identification and mitigation of organizational risks; Develops, implements, and sustains a continuous regulatory compliance readiness program and promotes the culture of compliance in everyday practice throughout ECHCS; Translates accreditation standards, directives/handbooks, policies, and other regulatory requirements into action within the complex interrelationships that exist related to external accreditation/review; Obtains and submits protected and confidential official complaints after direct consultation with executive leadership. You will be rated on the following Competencies for this position: Creative ThinkingExternal AwarenessFlexibilityInfluencing/NegotiatingProblem SolvingProject ManagementQuality AssuranceQuality ManagementTeaching OthersWriting Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. Physical Requirements: No special physical exertion is required other than walking in a large 1.2M square foot primary facility. The work is primarily performed while sitting though some work requires periods of standing. The regular and recurring work of the position involves sitting at a desk, conferences, meetings, etc., and occasional visits to activity work sites. Occasionally incumbent is required to carry light objects, such as files, mail, laptops, supplies and papers. The incumbent will be required to move wheeled tables and chairs as needed for training or conferences. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

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.

Contacts

• Address Eastern Colorado HCS Denver 13611 E. Colfax Ave Aurora, CO 80045 US
• Name: Jennette Stroud
• Phone: 515-323-1412
• Email: [email protected]