The Primary Purpose of the Position: The incumbent serves as the Quality Management (QM) Specialist for the Environment of Care/Life Safety (ELC/LS) reporting to the Quality Manager. Organizational Location: The Organizational Location of the Position is: Quality, Safety and Value service and is aligned under Quality Management (QM) section, VANTHCS, Dallas TX.

Duties

Duties include but are not limited to: The QM Specialist is responsible for the appropriate interpretation of The Joint Commission (T JC) standards (Engineering, Life Safety, Emergency Management Chapters) for hospital, home care, and behavioral health survey activities; additionally, interpretation of Office of Inspector General (OIG) guides, VHA directives and guidelines, medical center polices, and other applicable accrediting bodies such as Commission on Accreditation of Rehabilitation Facilities (GARF) and Long-term care survey contract. QM liaison to the following survey readiness teams (Life Safety, Human Resources, Records Management, Emergency Management, Patient Rights, Environment of Care). The QM Specialist will be accountable to follow policies and procedures, medical center policies (MCP), standard operating procedures (SOP), competencies, directives and all guidelines that are applicable to Life Safety and Environment of Care. Completes Environment of Care/Life Safety, Human Resource and Patient Rights tracers throughout the facility. The QM Specialist is the Quality Management representative for the Home Oxygen Committee and provides consultation guidance on standards compliance for the program. The incumbent has responsibility for managing the Joint Commission Resources (JCR) AMP tracer program and works with all teams to ensure tracers are built and entered into the program timely. The QM Specialist will be responsible for the ongoing development and maintenance of a continuous readiness program which ensures facility accreditation and compliance with external accrediting standards and internal performance expectations as delineated in VHA guidelines and directives. The QM Specialist has continuous responsibility of the changes in accreditation process, i.e., TJC, OIG, and other accrediting and review bodies. The incumbent keeps abreast of such publications and notices of updated information and educates T JC survey preparation team leads, leadership and other stakeholders on any updates to facilitate communication and transparency. The incumbent communicates the OIG Comprehensive Healthcare Inspection Program review guides to the responsible services annually to prepare for the upcoming surveys and obtains all required documents for the survey team. Coordinates the T JC triennial surveys and ensures all survey findings are resolved within the designated timeframes. Provides actions plans for each survey finding to T JC and ensures sustained improvement occurs over time. The incumbent will update and complete required T JC annual application update for the VANTHCS and transmits completed application. Facilitates and obtains all required documentation per the T JC survey guides prior to unannounced surveys. The documents are presented to T JC surveyors upon their arrival for an unannounced survey. The incumbent will promote a culture of continuous readiness within an enterprise risk management framework, driving improvement and developing processes which support a safe environment of patient care and physical plant. Achievement of these responsibilities will require strong skills in leading and facilitating both large and small interdisciplinary groups seeking systems improvement outcomes; teaching; writing; document review; data extraction, evaluation, and trending; electronic data reporting, including development of spreadsheets, tables, and graphs; project management skill; presentation development; priority-setting and critical thinking skills. The QM Specialist coordinates all activity of the Joint Commission Survey Readiness Compliance Teams by providing education and the organization of teams for each Joint Commission chapter. The QM Specialist will conduct special assignments as delegated by the Quality Manager in relation to performance improvement issues, the overall hospital mission, and/or items in the best interest of the Department of Veterans Health Administration. compiles information and data, coordinates Develops guidelines and new methods to address deficiencies and implement improvements. Performs other duties as assigned and provided coverage needs as requested for the Quality Manager. Work Schedule: Monday-Friday, 7:30am to 4:00pm 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. (Ad-hoc) Position Description/PD#: Management & Program Analyst/PD005840 Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not Approved Permanent Change of Station (PCS): Not Authorized

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 09/10/2024. 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. 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: Experience: One year of specialized experience, equivalent to at least the GS-09 level in the federal service, that equipped me with the knowledge, skills, and abilities needed to successfully perform the duties of this position and that is typically in and/or related to the position being filled. Specialized experience includes: Utilizes a variety of data sources including the CPRS, VistA, JPSR, VSSC, and Power Apps; Knowledge of clinical practices and medical terminology to effectively communicate with staff and facility leaders to process; Uses analytical, evaluative, and problem-solving skills and techniques to plan and conduct comprehensive data reports; and Skilled in written and oral communication sufficient to prepare and present findings and recommendations OR, Education: Possess a degree equivalent to at least the 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 (TRANSCRIPT REQUIRED) OR, Experience/Education Combination: Combination of education and experience as described above - only education in excess of a master's degree will be considered for combining education and experience. (TRANSCRIPT REQUIRED) You will be rated on the following Competencies for this position: Compliance Inspection Communication Analysis and Problem Solving 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 sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds. 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

To qualify on education alone, 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 is required.

Note: 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/.

NOTE: If your school has changed names, or is no longer in existence, you must provide this information in your application.

Contacts

• Address Dallas VA Medical Center 4500 South Lancaster Road Dallas, TX 75216 US
• Name: VISN 17 SSU USAS Group
• Email: [email protected]