The incumbent is assigned to the OQPI service and leads accreditation readiness processes for Boise VAMC Medical Center programs including The Joint Commission (TJC )(Hospital, Behavioral Health, and Home Care), Commission on the Accreditation of Rehabilitation Facilities (CARF), the Office of the Inspector General (OIG), and other internal and external reviews.Learn more about this agency
The duties are but not limited to:
- Performs duties that directly contribute to both the continual accreditation of BVAMC programs and the quality and safety of patient care they provide.
- Facilitates the development, implementation, and sustainment of proactive and corrective improvements in order to meet accreditation standards and other regulatory and Veterans Affairs (VA) and Veterans Health Administration (VHA) requirements.
- Facilitates, supports, and assures completion of ongoing assessments and quality monitoring actions by service/subject matter experts to evaluate compliance with regulatory and accreditation standards
- Maintains current documentation and data as required for continual readiness
- Completes survey-related administrative processes and applications
- Provides consultation and support to all levels of facility leadership, the OQPI Chief and others responsible for BVAMC accreditation activities, including accreditation related requirements, BVAMC policy initiation/revision, readiness preparation, intra-survey facilitation, and development, implementation, and monitoring of post-survey corrective action plans
- Ensures that senior leaders are fully informed about the accreditation program and engaged in final compliance decisions and approval processes for program related products and activities, as appropriate.
- Plans, facilitates, conducts and documents BVAMC tracers, walkabouts, and quality monitoring audits, as scheduled and as needed, focusing on continual survey readiness and evaluation of specific corrective action plans
- Evaluates patient medical records for compliance with inpatient and outpatient services' policies and accreditation requirements. Interviews staff and to assess and improve compliance with regulations and guidance. Initiates, conducts, evaluates, and documents risk assessments, reporting findings and recommendations to leadership. Participates in or facilitates process improvement teams as required. Participates on BVAMC committees as an accreditation and quality content expert.
- Educates staff about accreditation-related regulations, standards, and VA/VHA/VISN 20/BVAMC guidance and processes and OIG initiatives
- Provides consultation to ensure that BVAMC Medical Center Memoranda correctly and completely address accreditation-related requirements.
- Evaluates accreditation and quality monitoring data and recommends improvement actions, through informative reporting as required, to facility committees, boards, councils and leadership staff.
- Competently executes position responsibilities in a manner that demonstrates substantial and continuous leadership, responsibility, and accountability for oversight of population groups and integrated multidisciplinary programs, and support for safe, high quality patient care and organizational initiatives
- Utilizes critical thinking, clinical reasoning, and evaluation skills, integrated with accreditation and clinical knowledge, evidence based practice, best practice recommendations, and Pl strategies/processes to examine BVAMC programs, processes, and staffs' practice performance; and initiate plans to effectively develop, improve, and sustain patient care quality and safety.
- Builds effective, flexible, results-oriented teams to identify and solve problems and meet accreditation requirements.
- Advocates for, leads, and manages organizational change to improve patient care safety and quality
- Creates effective lines of communication and collegial, collaborative functional partnerships with senior leadership, internal and external customers, and accreditation stakeholders.Uses adult learning principles to educate staff about accreditation-related requirements and promote organizational continual readiness.
- Meets goals through efficient, effective utilization and management of organizational and personal resources.
Financial Disclosure Report: Not required
Job family (Series)
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/560583700. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.