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Provides executive-level nursing leadership, oversight, and coordination of organizational Quality and Patient Safety programs across multiple services and disciplines.
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Supervises Quality and Patient Safety personnel, including providing guidance, performance evaluations, professional development, and support for organizational change and improvement initiatives.
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Assesses, plans, implements, coordinates, monitors, and evaluates quality management and patient safety programs to promote safe, effective, and Veteran-centered healthcare delivery.
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Provides leadership in maintaining compliance with applicable VHA directives, regulatory requirements, accreditation standards, and organizational policies and procedures.
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Facilitates organizational accreditation readiness activities in collaboration with the Survey Coordinator, including standards compliance, staff education, and monitoring of corrective actions.
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Supports compliance with external oversight and regulatory organizations, including The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), Occupational Safety and Health Administration (OSHA), Office of the Medical Inspector (OMI), and Office of Inspector General (OIG).
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Oversees monitoring and follow-up of corrective actions resulting from regulatory surveys, accreditation findings, and identified performance deficiencies.
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Coordinates and provides oversight of quality and patient safety activities, including Joint Patient Safety Reporting (JPSR), tort claims, and peer review programs.
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Conducts and oversees clinical quality reviews, clinical data analysis, and evaluations of healthcare processes to identify opportunities for improving patient safety and clinical outcomes.
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Monitors organizational performance measures, including Strategic Analytics for Improvement and Learning (SAIL) outcomes and External Peer Review Program (EPRP) metrics.
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Identifies quality indicators, analyzes performance trends, and maintains organizational quality dashboards to support data-driven decision-making and performance improvement.
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Serves as a subject matter expert in clinical quality data analysis, interpretation, presentation, and utilization to improve healthcare outcomes.
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Provides consultation and guidance to medical center leadership and staff regarding standards interpretation, patient safety, infection prevention, risk management, and process redesign.
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Develops, implements, and evaluates policies, procedures, and clinical processes designed to improve patient safety, quality of care, and organizational performance.
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Leads performance improvement initiatives by identifying gaps in healthcare delivery, evaluating organizational processes, and implementing evidence-based corrective actions.
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Collaborates with interdisciplinary healthcare teams and service leaders to develop and implement sustainable improvements in patient care and operational efficiency.
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Supports Quality and Patient Safety programs, including accreditation, system redesign, infection prevention, patient safety, risk management, High Reliability Organization initiatives, and evidence-based practices.
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Provides leadership in strategic planning and aligns quality improvement initiatives, organizational resources, and performance measures with medical center goals.
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Promotes effective utilization of organizational resources through evaluation of clinical and nonclinical operations, business processes, and performance outcomes.
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Participates in and provides leadership to medical center committees, councils, workgroups, and interdisciplinary improvement initiatives.
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Facilitates communication and collaboration among clinical and administrative staff to promote organizational accountability, teamwork, and continuous improvement.
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Provides education, consultation, mentoring, and professional development opportunities to healthcare staff regarding quality management, patient safety, and regulatory compliance.
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Performs other duties as assigned.
50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)