Summary
The Chief of Quality Management serves as the facility lead for quality management, performance improvement, systems redesign, and related quality oversight programs. The position reports to the Medical Center Director and has oversight of Continuous Readiness, Utilization Management, Risk Management, Patient Safety, External Peer Review (EDRP), Systems Redesign, VASQIP, and Infection Control.
Duties
Quality and Compliance - 50 % Supervises and provides administrative and program oversight for risk management, patient safety, systems redesign, infection control, external peer review, and related quality management programs as assigned by the Director. Coordinates the integrated relationship of these programs to each other and with the organization as a whole to minimize duplication and clarify respective functions. Monitors the status of Quality Management programs and related initiatives affecting patient care quality and regulatory compliance. Monitors areas related to improving the quality of care and ensures effective systems are in place. Develops procedures to all administrative and clinical committees and service meetings Ensures continuous readiness and compliance for various external site reviews, including The Joint Commission (TJC), Office of Inspector General (OIG), Commission on Accreditation of Rehabilitation Facilities (CARF), Community Living Center (CLC) Survey, and Office of Medical Inspector. Collaborates with the chairs of key system committees to develop compliance review schedules. Collaborates with executive leaders in the development and implementation of quality management policies and performance improvement strategies. Analyzes services provided and organizational resources to determine alternative resource allocations and make recommendations to executive leadership. Provides performance improvement direction and advice to various system committees and follows up on recommendations to VAEKHCS executive boards and committees to ensure the timely resolution of identified problems. Prepares performance improvement agendas and briefs for the ELT, highlighting issues and progress. Provides oversight for major performance improvement projects, collaborating with VAEKHCS management to ensure full implementation of recommendations, as well as VHA mandates. Educates and trains staff on performance improvement methodology and evaluation. Advises and collaborates with service leaders regarding the development, implementation, evaluation, and improvement of clinical and administrative programs. Consults with service chiefs, committee chairpersons, and program managers to develop and execute service and program strategies that align with VAEKHCS Strategic Plan and VHA Performance Measures. Directs the QM Service, responsible for multiple programs focused on monitoring quality and performance metrics and performing studies to analyze and improve operations. Programs include Continuous Readiness, Utilization Management, Risk Management, Patient Safety, External Peer Review (EDRP), Systems Redesign, VASQIP, and Infection Control. The mission of the service line is a combination of complex administrative and technical evaluations and professional collaboration, oversight, and analysis. The program directly affects accreditation readiness, regulatory compliance, patient safety oversight, and organizational performance. Program findings and recommendations support executive leadership decisions regarding corrective actions and continuous improvement initiatives. The incumbent provides administrative and technical supervision to 15 employees working in the QM service. The incumbent is responsible for the administrative supervision of ten (10) Title 38 employees. The incumbent plans work to be accomplished by subordinates, sets and adjusts short-term priorities, and prepares schedules for completion of work; Assigns work to subordinates based on priorities, selective consideration of the difficulty and requirements of assignments, and the capabilities of employees; Evaluates work performance of subordinates; Gives advice, counsel, or instruction to employees on both work and administrative matters; Interviews candidates for positions, selecting, promoting or reassigning candidates to such positions; Hears and resolves complaints from employees, only referring more serious unresolved grievances and complaints to the Health System Director; Effects minor disciplinary measures, such as warnings and reprimands, recommending other actions in more serious cases; Identifies developmental and training needs of employees, providing for and arranging for needed development and training; Identifies ways to improve production or increase the quality of work directed; Develops performance standards; Approves and disapproves annual and sick leave. Work Schedule: Monday - Friday, 8:00AM - 4:30PM Position Description Title/PD#: Supervisory Health System Specialist/PD105530 Physical Requirements: The work is primarily sedentary with some walking or standing. No special physical demands are required. 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.
Requirements
You must be a U.S. citizen to apply for this job Subject to a background/suitability investigation Selective Service Registration is required for males born after 12/31/1959 A complete application package; Resume, Transcripts, etc. is required Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Upon completion of your probationary period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service Upon completion of your probationary period or trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.
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.
How you will be evaluated
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Applicants will be referred in the order in which they were received.