This position serves as a Program Analyst in the Office Of High Reliability/Quality at the Kansas City VA Medical Center, providing comprehensive accreditation education, communication, and consulting support to the facility for the maintenance of health care accreditation and promotion of standardization, continuous improvement, and sustained compliance.

Duties

Duties include but may not be limited to: Tracks all action plans identified in TJC, CARF, and all other surveys and inspections, and reports that information to the pertinent committees, councils, services and Leadership. Plans and manages the medical center's accreditation and review programs - targeting areas that require application of improvement principles to meet Joint Commission, Commission (TJC) Commission on Accreditation of Rehabilitation Facilities (CARF), VISN 15, VHA, Office of the Inspector General (OIG) and/or other regulatory elements of performance. Serves as the nexus for all information relating to accreditation and survey programs. Ensures coordination of all logistical matters associated with site visits and surveys from oversight, regulatory, and accrediting bodies. Develops and implements systems to ensure Quality Management documents are retained and organized according to VHA Records Management directives and Quality and Patient Safety directives by creating schedules, file and documentation organization, and standard work. Develops metrics for directing implementation, evaluating effectiveness, and monitoring for sustained improvement. Prepares and maintains reports for compliance programs. Uses databases, spreadsheet, software and statistical and graphic software to organize data, perform analysis, and present in a visual form that will convey complex information in a clear and concise manner. Develops and institutes preventive maintenance requirements for equipment related to the compliance program. Develops, implements, and updates local policies. Provides education and support to medical center leadership who are responsible for drafting action plans or other responses required to oversight, regulatory, and accrediting bodies. Provides status reports to service line and advises supervisors of specific areas that need attention. Attends all accreditation related meetings requiring a team representative. Works collaboratively with education and content experts in the development of educational and discipline appropriate materials to support the accreditation improvements and integration of those materials into the organizational systems. Interacts and communicates with administrative and clinical staff, leadership, individuals from the VISN, the public (contractors and vendors both potential and actual), and other government agencies. Performs other duties as assigned. Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. Work Schedule: Monday-Friday 7:30 am - 4:00pm Compressed/Flexible: Not Authorized Telework: Ad-hoc Virtual: This is not a virtual position. Position Description/PD#: Program Analyst - Accreditation and Survey Coordinator/PD00000/10260 Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not Authorized 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, 06/21/2024. 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-11 position you must have served 52 weeks at the GS-09. 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: GS-11 Requirements: Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-09 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Applying analytical and evaluative methods and techniques to issues or studies concerning the efficiency and effectiveness of program operations. OR, Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have successfully completed a Ph.D. or equivalent doctoral degree or 3 full years of progressively higher level graduate education leading to such a degree or LL.M., if related that demonstrates the knowledge, skills, and abilities necessary to do the work of this position. NOTE: Transcripts must be submitted with application. Education cannot be credited without documentation. OR, Combination: Applicants may also combine education and experience to qualify at this level. You must have a combination of specialized experience as described above and graduate level education beyond 36 semester hours (or 2 years) that provided the knowledge, skills, and abilities necessary to do the work of the Program Analyst position to meet the total experience requirements for this grade level. GS-12 Requirements: Specialized Experience: 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: Utilizing knowledge of accrediting bodies such as The Joint Commission to ensure compliance with policies/laws/directives; analyzing and evaluating data; and preparing reports. You will be rated on the following Competencies for this position: AuditingChange ManagementCommunicationDecision MakingInfluencing/NegotiatingOrganizational DevelopmentOrganizational Performance Analysis 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: The work is primarily sedentary, although some slight physical effort may be required. 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

There is no educational substitution for the GS-12 level.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Kansas City VA Medical Center 4801 Linwood Boulevard Kansas City, MO 64128 US
• Name: Fallon Bailey
• Phone: (410) 336-5277
• Email: [email protected]