Summary The Quality and Patient Safety (QPS) Chief is an advanced health care executive who executes responsibilities that demonstrate leadership, experience and innovative approaches in the guidance and direction of a variety of complex patient care programs and services. This position is located in the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Mid Atlantic Health Care Network (VISN 6), Durham VA Health Care System (DVAHCS), in the office of the Director. Responsibilities The Durham VA Healthcare System (DVAHCS) is a 151 operating bed medical center that offers primary, secondary, and tertiary diagnostic and therapeutic health services in medicine, surgery, neurology, rehabilitation medicine, transitional care, dental care, oncology and radiation therapy, skilled nursing home care, and palliative care to adult and geriatric populations. Primary and secondary levels of inpatient and outpatient psychiatric care are also provided. The health care system center is also home to multiple research centers including GRECC and MIRECC. The Quality and Patient Safety (QPS) Chief functions as an advisor, administrator, educator, consultant, and mentor who possesses a wide range of experience and leadership ability. The Quality and Patient Safety Chief must establish and maintain effective relationships with all levels of Veterans Integrated Services Network (VISN) and health care system personnel and relate effectively with customers, families, and the community as well as program and service leaders at the local and network levels. Key relationships with staff are needed to assist team to carry out the functions and activities expected of them. Duties of the Nurse (Chief Quality and Patient Safety) include but are not limited to the following: Key leader in strategic planning, organizational assessment, and development of facility program development Assist in policy-making activities as related to customer service and the overall functioning of administrative and clinical programs Contribute ideas and recommendations for the establishment of standards of care, policies, and objectives for the enhancement of quality management organization wide Provides senior leadership and oversight for daily clinical and administrative operations within Quality Management (QM) Program Participates with the ELT and strategic thought leaders in Medical Center to initiate and execute planning and decision- making processes for their program Possess the authority and responsibility for establishing standards of quality across all levels of the health care system ensuring quality of care across the Medical Center Provides executive leadership and direct supervision for Patient Safety, Risk Management, Protected Peer Review, Accreditation Management and Continuous Readiness, Quality Consultants, Utilization Management, Systems Redesign, Policy Documentation and High Reliability Organization Programs Collaborates with both administrative and clinical services to monitor quality and safety within the service and health care system Coordinates and provides oversight of programs through assessment and analysis of data to identify compliance issues and oversees efforts that assure Joint Commission, OIG, OMI, and other applicable standards are monitored and actions are taken when needed to meet the standards Reviews and analyzes Performance Measures, External Peer Review Program (EPRP) data, Veterans Affairs Surgical Quality Improvement Program (VASQIP) data, Inpatient Evaluation Center (IPEC), Strategic Analytics for Improvement and Learning (SAIL) and other quality date trends for early intervention Applies clinical performance improvement methods, collects outcome data related to policy, procedure, and regulatory compliance and in collaboration with management, initiates performance improvement monitoring projects Utilizes data and comparative analytical processes in recommending design and implementation of innovative programs to improve service excellence, customer satisfaction, and compliance to patient care and regulatory standards 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: Monday - Friday 7:30am - 4:00pm EST Compressed/Flexible: May be authorized at the service chief's discretion Telework: ADHOC-May be authorized (Employees who Telework on an occasional, episodic, or short-term, and have completed required telework training and telework agreement) Relocation/Recruitment Incentives: Recruitment incentive may be authorized for highly qualified applicants Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Requirements Conditions of Employment U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details. 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. The following Scope, Education and Dimension criteria must be met to qualify for Nurse V: Scope: Practice of an executive nature, comprised of complex leadership and administrative components, associated with critical health care issues and activities that drive meeting the organizational mission, health care and policy. Education: Master's degree in Nursing (MSN) and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR Master's degree in a *related field with a BSN and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in Nursing and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in a *related field with a BSN and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V. *Note: Foreign education programs/degrees are not creditable as related degrees. Dimension Requirements: Leadership. Establishes the strategic direction for health care delivery, evidence-based practices, industry-leading research, and innovative care models. Creates a shared vision and successfully leads change to improve performance and attain measurable outcomes at the organization or enterprise level. Business Acumen. Transforms health care through the application of new processes, technology, informatics, data analytics, business principles, systems thinking and resource management at the organization or enterprise level. Inspiring an Industry-Leading Culture. Establishes an industry leading, shared decision-making culture; a diverse and inclusive workforce that serves Veterans, families, and caregivers of all backgrounds; builds trust and cultural competencies and catalyzes dynamic teams at the organization and enterprise level. Communication and Relationship Management. Drives the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional and organizational values, beliefs, and practices at the organizational or enterprise level. Professional and Social Responsibility. Sets the standard for a culture of holistic care, health advocacy and health equity. Applies ethical principles in decision-making at the organization or enterprise level. Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans, the community, and the health care industry. Preferred Experience: Ability to work effectively with employees, customers, vendors and members of the interdisciplinary matrix Ability to use computer software in support of preparing and presenting reports and analysis Ability to coordinate and evaluate integrated programs Clinical excellence in management of groups Experience in accreditation standards, VHA regulations and directives Knowledge of current techniques, trends and professional issues, and organizational improvement Minimum of four to five years of successful nursing practice Minimum of two years of successful management experience in Quality Management and System Redesign Preferred Certification(s): ANCC Nurse Executive Leadership Certification & Certified Professional in Healthcare Quality (CPHQ) Lean Six Sigma CPUR Certified Professional in Utilization Review CPUM Certified Professional in Utilization Management CPHM Certified Professional in Health Care Management CPHQ Certified Professional in Health Care Quality Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. 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 complete annual Employee Health requirements, such as annual TB screening or testing, as a condition of employment. Education Nursing Bridge Programs: Nursing bridge programs are accelerated nurse education programs which rely upon existing nursing knowledge and education. Graduates from nursing bridge programs that meet accreditation requirements specific grade level requirements in this standard must also be met in addition to the following: a) Master's Level Bridge Program Education Appointments Prior to Graduation. Individuals attending a master's level bridge program in nursing who achieve the level in their education in which they 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 a temporary basis for any period up to three years contingent upon full completion of the professional nursing education program, if education verification provided by the school supports the Bachelor of Science in Nursing (BSN) equivalency. Upon successful completion and graduation from the bridge program, the Nurse may be converted to a permanent appointment under the provisions of section 7401(a)(1) of title 38. Failure to complete the bridge program on which the temporary appointment was based will result in termination of the appointment. Degree in a Related Field: A graduate level or doctorate degree in health care/management related fields from an institution accredited by the State and approved by the Department of Education at the time the candidate completed the program may be credited as specifically indicated in grade requirements. The graduate level or doctorate degree and coursework must provide evidence in support of the nursing role and duties associated with the assignment and grade level. Foreign education programs/degrees are not creditable as related degrees. 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. Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.