The incumbent serves Hines VA as a Quality Improvement Specialist (facilitator, coordinator, and advisor) and is directly responsible to the Chief of Quality & Patient Safety. The incumbent will be assigned responsibility for support of specific patient care areas.

Duties

The Quality Improvement Specialist is responsible for working closely with assigned Service Line Leadership to develop and implement its performance improvement plan and activities. The Quality Improvement Specialist is accountable for providing leadership and guidance to develop, implement, refine, and maintain a comprehensive quality management/improvement program. The incumbent is responsible for the following: Trending and analyzing data, interpreting Joint Commission and other external agency standards Interpreting VHA handbooks and directives regarding quality management/performance improvement/patient safety issues Collaborating with the facility Patient Safety Officer Collaborating and assisting in system redesign processes and monitoring progress of reviews and follow-action items to ensure completion in a timely manner. Responsible for coordinating and maintaining a comprehensive, organized, continuous readiness program to review and identify opportunities for improvement in order to achieve excellence in the delivery of healthcare. Assists in developing Quality Improvement processes to assure that all required information is procured and acted upon to meet the expectations of the facility, Joint Commission, VHA Headquarters, Office of the Medical Inspector, Office of Inspector General or other external organizations. Responsible for all directives and standards relating to the Quality Management program for areas within assigned responsibility. Assists the Service Line and ensure performance improvement processes are in place, follow-up is conducted, and outcome reported. Conducts reviews to evaluate compliance with program regulations, policies and procedures and assists with the development of facility policies and procedures as appropriate Assists in develop Quality Improvement approaches for standardizing system related procedures to minimize variation. Supports facility activities in the coordination and development of data collection and analysis techniques, primarily in the areas of specific Performance Measures and Performance Improvement indicators. Reviews all performance improvement data for assigned areas and assists responsible staff in initiating/facilitating appropriate action based on VA guidance documents. Facilitates education of personnel, both in the facility orientation of employees on performance improvement and in specific training for those involved in the performance improvement activities within services, on hospital Quality Improvement committees and/or within process action teams. Conducts various patient care studies based on areas assigned, including review of patient incident report reviews, utilization management reviews, medical record reviews for evidence of required documentation as well as the quality and level of care provided. Conducts tracers, operational assessments and participates in the design of special studies to define the cause and scope of issues or trends and assists in the identification of appropriate criteria for problem resolution. Analysis includes trend, pattern and other statistically valid techniques to assist in focusing program attention and efforts. Participates in the development of innovative approaches to the establishment, enhancement, modification, and/or improvements in a variety of facility programs related to performance improvement/quality management. Reviews service/section/committee meetings for results of assessment and improvement activities including conclusions, recommendations, actions and evaluations. Closely monitors and advises services and committees of Quality Improvement topics that need to be addressed at meetings in order to meet The Joint Commission standards compliance. Facilitates and maintains a record tracking system for monitoring a variety of information, potential problem areas and action plans, and coordinates action plans for addressing opportunities for improvement. Evaluates achievement of objectives based on planned levels and actual performance, assessing status and develop Quality Improvement plans. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 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 Work Schedule: 8-Hour Tours variable between 6:00am to 6:30pm Telework: Not Available Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required

Requirements

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 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). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. 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: Master of Science Degree in Nursing (MSN) 2 to 4 Years' RN Experience Basic Life Saving (BLS) Certification Required Must be available for official travel as required 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 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years 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 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. 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 comply with any Employee Health requirements 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.

Contacts

• Address Edward Hines Junior Hospital 5000 South 5th Avenue Hines, IL 60141 US
• Name: Irene Balas
• Phone: 708-640-4736
• Email: [email protected]