Clarification from the agency

AREA OF CONSIDERATION: Open to current, permanent Milwaukee VA Medical Center employees only (includes CBOCs and VCS). NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

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Responsible for the ongoing development and maintenance of the facility Patient Safety Program that is derived from the Patient Safety Handbook of the VA National Center for Patient Safety and appropriate VHA directives. The incumbent will promote a culture of patient safety, High Reliability Organization (HRO) and utilizing an enterprise risk management framework. Achievement of these responsibilities will require strong skills in the leading of interdisciplinary groups, teaching; written communication, medical record review, data evaluation and trending, electronic data reporting, including development of spreadsheets, tables and graphs, project management, presentation development, priority-setting, and critical thinking skills.

The Patient Safety Manager functions as a coordinator and point of contact for patient safety policies and activities developed by the VA National Center for Patient Safety (NCPS). The incumbent will work with the Patient Safety Manager team to help build and implement patient safety systems related to a variety of safety initiatives, including medication processes, promoting the culture of safety for both patients and staff in all healthcare settings at the Milwaukee VAMC. Guiding policies are found in the VHA National Patient Safety Improvement Handbook (directive), national patient safety training materials and computer systems, current literature, and applicable regulations of the Joint Commission. The incumbent will provide direct support in the development, maintenance, and operation of the VHA's Patient Safety Program at the facility level.

Duties:

• Evaluates the quality and effectiveness of clinical performance within the facility, using data collected by internal and external monitoring processes. Relays this information to clinical leadership and senior leaders.
• Provides day-to-day evaluation of situations which might pose clinical risk, implementing risk mitigation strategies to improve clinical care delivery. Develops relevant risk mitigation plans and tracks clinical outcomes to determine compliance with, and sustainability of, said plans.
• Completes individual quality reviews and/or case assessments to determine which improvement efforts are necessary to improve clinical care delivery. Implements relevant improvement strategies, which may include, but are not limited to, one-on-one teaching, group educational sessions, process redesign, and/or peer review.
• Determines if clinical error has occurred. Develops a plan to address such error.
• Utilizes knowledge of medical terminology, anatomy, physiology, medical diagnoses, reading and interpreting orders, lab values, progress notes, medications, and treatment plans, to be able to determine and discuss the appropriateness of health care provided by various clinical professionals at VA CCHCS.
• Gathers and integrates knowledge from databases of adverse events and safety alerts from many different sources, including Food and Drug Administration (FDA), Institute for Safe Medication Practice (ISMP), The Joint Commission (TJC), and Centers for Disease Control (CDC).
• Provides accurate and timely electron clinical data reports and assessments to the Quality Chief, Quality Manager, QSV, the Executive Leadership Team, facility service chiefs, and VISN 12 patient safety staff as appropriate.
• Plays a critical support role in developing and coordinating internal review systems to ensure that both clinical and administrative activities are in compliance with agency and accrediting and regulatory requirements.
• Maintains program requirement/validation criteria for the facility's patient safety program.
• Maintains comprehensive knowledge of the range of administrative laws, policies, regulations, and precedents applicable to the administration of the Patient Safety Program. This includes knowledge of VHA National Center for Patient Safety's goals and objectives, the sequence and timing of key program events and milestones, and methods of evaluating the worth of program accomplishments at the local level.
• Assists in developing clinical reviews and/or audits to analyze problems in depth, including selection of study samples, identification of data required to define the problem, establishing data collection methodologies, analyzing the data, recommending corrective action when necessary, and assessing effectiveness of the action.
• Has primary responsibility for training and implementation of the patient safety, RCA, and Healthcare Failure Mode Effect and Analysis (HFMEA) process to clinicians, management, and all relevant support personnel within their facilities and associated facilities and operations.

Work Schedule: Monday-Friday; 8:00am to 4:30pm
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 09639F
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• 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.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• 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.
• 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).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial 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 trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:

• Citizenship: Must be a US Citizen.
• English Language Proficiency: Must be proficient in spoken and written English in accordance with 38 U.S.C. § 7403 (f).
• Education (TRANSCRIPTS REQUIRED):
  • A bachelor's degree or higher from an accredited college or university.
• Certification: Candidates must meet one of the certification options below.
  • (a) Generalist certification as an MLS given by ASCP BOC or AMT.
  • (b) Generalist certification as an MT given by ASCP BOR or AMT.
  • (c) Categorical certification or Specialist certification by ASCP or AMT.

Grade Determinations:

• Experience: Must have at least one (1) year of creditable experience equivalent to the next lower grade (GS-12).

OR,

• Education. Must have three (3) full years of progressively higher-level graduate education or a Ph.D. or equivalent doctoral degree in medical technology or a directly related science.

GS-13 Knowledge, Skills, and Abilities: In addition to the experience or education above, the candidate must demonstrate the following KSAs.

• Knowledge of regulatory and accrediting agency requirements, concepts, principles, and practices of medical technology sufficient to perform the full range of duties involved in planning, coordinating, and evaluating laboratory services.
• Knowledge of compliance requirements sufficient to provide direction for complex diagnostic testing.
• Knowledge of laboratory information systems to accomplish diagnostic laboratory work and quality assurance.
• Skill in evaluating, interpreting, and teaching others to use quality control procedures to monitor variables that affect quality of services and implement corrective actions.
• Ability to apply laws, policies, precedents, regulatory, licensing, and accrediting requirements to establish, monitor, and maintain the specialized testing.
• Ability to develop new test procedures and modify existing procedures and methods to resolve problems relative to complex and difficult situations.

Additional Special Qualifications:

• Ability to communicate orally to individuals and groups of people in person while at conferences, via video-conferencing and during teleconferences
• Ability to communicate in writing for a variety of purposes including the preparation of reports and analysis, publications, and newsletters
• Ability to organize projects of broad scope and objective without the use of established methods and procedures
• Knowledge of VA National Center for Patient Safety reporting systems
• Knowledge of VA Organizational Structure Maintain clinical licensure

Preferred Experience:

• Minimum of 5 years clinical experience.
• Understanding of Patient Safety Improvement Program according to the VHA National Center for Patient Safety (NCPS) guidelines, The Joint Commission (TJC) and the High Reliability organizational Programs (HRO)
• Experience with project management, Root Cause Analysis (RCA), and Healthcare Failure Mode and Effect Analysis (HFEMA)
• Previous experience in leadership, supervisory, or mentorship role
• Excellent verbal and written communication skills.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is 13.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

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.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.