Summary Responsibilities of this role is oversight and assistance with specific program management duties related to External Peer Review Program (EPRP), CLC, Home Based Primary Care (HBPC) and Mortality reviews. The RN coordinates the activities associated with the External Peer Review Program (EPRP) and coordination of the committee activities. Maintains and reports findings of mandatory Mortality reviews and identifies trends associated with mortalities and concerns after review of medical records. Responsibilities The CLC/HBPC/EPRP Registered Nurse Is the primary support and liaison for the CLC and HBPC for survey to assist the Survey Accreditation Facilitator. The primary roles and duties for this position are responsible for auditing and investigating that affect the internal security of the agency. This position is directly responsible for protecting the internal security of the agency through investigations/audits of patient care records for several purposes such as fact finding, sentinel events, surveillance, performance improvement, root cause analyses, FMEA, and regulatory agency requests (i.e. OIG, TJC, OMI, OWP, etc.) which affect the security of William S. Middleton Memorial Veterans Hospital by ensuring that the duties are discharged with honesty and integrity and the activities are imperative to the functional operation of the agency in carrying out its mission. The CLC/HBPC/EPRP Registered Nurse: Demonstrates expertise in the development, implementation, and evaluation of specific processes for the Organizational Improvement and Quality Program. Uses current trends and relevant theory to identify and analyze issues/problems and systematically analyzes clinical records. Maintains current knowledge in the field of Performance Improvement and clinical practice. Uses the Robust Improvement System to appropriately to develop, implement, and evaluate strategies to maintain and promote a program to improve outcomes. Evaluates the quality and appropriateness of patient care using established criteria. Uses systematic reviews to evaluate current clinical and administrative practices and to identify patterns and trends. Identifies changes needed to improve quality of care and initiates projects to address them. Evaluate current clinical and administrative practices using systematic reviews identifying patterns and trends. Provides leadership with specific performance improvement initiatives/projects. Identifies and evaluates evidence-based practice findings and best practices and recommends implementation when appropriate. Systematically collects and analyzes data, accurately interrupts the results, and reports findings with appropriate recommendations. Displays data in a clear manner. Uses benchmarking when available. Demonstrates expertise in accreditation standards and federal regulations, and serves as an internal resource for staff. Assist in developing and implementing strategies to improve compliance with external/internal accrediting bodies. Participates in the development of policies and procedures and assists with the implementation of them. Conducts policy review. Uses professional and scientific literature in problem-solving. Evaluates data for its reliability and validity. Uses evidence-based and research findings as appropriate to improve the quality of care. Instructs hospital staff in principles of Organizational Improvement. Attends educational activities and VA continuing education programs to increase knowledge related to Organizational Improvement. Completes mandatory annual reviews. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Work Schedule: 0730 to 1600. Telework: Not Authorized Relocation/Recruitment Incentives: Not Authorized 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). 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. Preferred Experience: BSN or Higher preferred Data abstraction and review experience preferred 2-3 years acute care experience preferred Accreditation continual readiness experience preferred 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/12887749. 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. 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: Walking, bending, stooping, and some lifting in the direct care of patients. There may also be extended periods of sitting. This position also requires that the staff member be able to wear a lead apron for an extended period of time. 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. Additional Information The William S. Middleton Memorial Veterans Hospital is committed to fostering and sustaining an environment which celebrates diversity, provides equitable opportunities for employment and promotion, and supports inclusiveness in our culture. Together, we strive to create and maintain working and learning environments that promote professional growth and teamwork, and are inclusive, equitable and welcoming. We embrace our differences as individuals and unite as a team toward a common goal: to serve our nation's Veterans. 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. 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.
