The incumbent serves Hines VA Hospital as a Quality & Performance Improvement (QPI) Consultant and is directly responsible to the Chief of Quality & Patient Safety (QPS). The incumbent is responsible for the management and oversight of the External Peer Review Program (EPRP) and identified performance /SAIL metrics, key performance measures linked to strategic priorities and organizational performance and other clinical areas as assigned.

Duties

The work of QPS is broad in nature covers a wide range of assessments that include health care outcomes, patient safety, risk management, organizational performance based on quality domains, accreditation, performance improvement, SAIL metrics, system redesign, infection control, oversight of and other categories. The incumbent is responsible for the following: collecting, analyzing, trending and interpreting data and converting such data into business intelligence in the form of charts, reports, presentations and other mediums as the Performance Measures Program Manager. The incumbent must stay knowledgeable of The Joint Commission (TJC) and other external agencies standards. He/she must review and interpret VHA handbooks and directives regarding quality management/performance improvement and patient safety issues. This requires collaborating with executive leadership, Pharmacy leadership, Patient safety managers and assisting in system redesign processes and monitoring progress of reviews and follow-action items to ensure completion in a timely manner. The incumbent is responsible for coordinating and maintaining a comprehensive, organized, continuous readiness program for assigned program areas assigned and to review and identify opportunities for improvement in order to achieve excellence in the delivery of healthcare. Incumbent 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. The incumbent is responsible for all directives and standards relating to the Quality Management program for areas within assigned responsibility. The incumbent will assist the service line and ensure performance improvement processes are in place, follow-up is conducted, and outcomes are reported. When required, he/she conducts reviews to evaluate compliance with program regulations, policies and procedures and assists with the development of facility policies and procedures as appropriate. The incumbent will assist in development of Quality Improvement approaches for standardizing system related procedures to minimize variation. The incumbent supports facility activities in the coordination and development of data collection and analysis techniques, primarily in the areas of performance measurement. Quality and Performance Improvement (QPI) EPRP/SAIL Registered Nurse (RN) demonstrates leadership, experience, and creative approaches to improvement in quality-of-care outcomes. The QPI EPRP/SAIL Consultant demonstrates performance that is broad enough to improve the care for a group of patients. The QPI EPRP/SAIL Consultant is responsible for the documented outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility. Program is defined as a substantial coordinated group of activities impacting patients and/or employees. The QPI EPRP/SAIL Consultant is assigned responsibility for their assigned quality management program area activities for the Medical Center and all off-site locations. The QPI EPRP/SAIL Consultant incumbent collects data, monitors staff compliance with relevant policies, directives, and standards, provides reports detailing trends, and provides direct staff support to all services in planning, designing, integrating, implementing, modifying, and administering, a comprehensive quality management program area. The QPI EPRP/SAIL Consultant participates in several facility councils, committees, and workgroups. Performs duties directly contributing to the administrative management of a health care delivery system. Duties require the ability to apply the specialized principles and practices of health care management in directing or supporting a health care delivery system. 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 available Monday thru Friday; Varies from 7:00 am to 6:30 pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Basic Requirements: 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 (ACEN) or The Commission on Collegiate Nursing Education (CCNE); 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 (ICD). 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.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12355491. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Preferred Experience: Masters Degree in Nursing (MSN) Minimum of 3 to 5 Years recent successful RN practice in complex acute inpatient/Med-Surg setting Experience in SAIL/EPRP and performance metrics 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 visual acuity, keen hearing, clear distinctive speech, and manual dexterity. The position requires potentially long periods of combined walking, standing, stooping, sitting, bending, pulling, and pushing. The incumbent must be a mature, flexible, sensible individual capable or working effectively in stressful situation, able to shift priorities based on needs of the organization. The incumbent who provides off-site training may be required to travel occasionally

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]