Surgical Quality Improvement Program RN

Full Job Description

The Veterans Affairs Surgical Quality Improvement Program Registered Nurse (VASQIP RN) is directly accountable to the Chief, Organizational Improvement.

The RN is responsible for the administrative and scientific conduct of the non-cardiac and cardiac components of the VASQIP, including, but no limited to, clinical screening, data compilation, documentation, and entry into the national database of all eligible patient cases.

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 Surgical experience preferred Quality management experience preferred Data management 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/12920367.

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. Major Duties:

The RN is expected to attend all program conferences associated with this program (Facility, VISN and national conferences).

Duties of 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 f 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 Nurse II VASQIP RN Prepares and presents clear, precise, and clinically accurate summaries of review findings including their significance and implications to Service Chiefs, Organizational Improvement staff, Executive Leadership, and others as appropriate.

Prepares or assists with the preparation of appropriate clinical criteria or benchmarks for medical review.

Comprehends and effectively analyzes the clinical contents of medical records and associated documents in terms of quality and appropriateness of care issues such as adherence to or deviation from accepted diagnostic and treatment protocols, including drug therapies and the presence or absence of expected outcomes.

Analyzes data and recommends improvement actions for the purpose of improving patient care management.

Uses appropriate Performance Improvement principles to plan, implement, and evaluate Pl processes that address improvement opportunities.

Maintains current knowledge in the field of Performance Improvement and clinical practice. Systematically analyzes clinical records.

Refers clinical records which do not meet review criteria, or which require medical expertise in clinical interpretation to physician/dental advisors.

Safeguards and maintains confidentiality in all aspects of accessing and accountability printed and electronic files containing sensitive data which must be protected per the provisions of the Privacy Act and other applicable laws, Federal Regulations, VA statutes and policy.

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.

Provides leadership with specific performance improvement initiatives/projects as a result of VASQIP data review.

Identifies and evaluates evidence-based practice findings and best practices and recommend implementation when appropriate.

Systematically collects and analyzes data, accurately interprets the results, and reports findings with appropriate recommendations. Displays data in a clear manner. Uses benchmarking when available.

Serves as a resource for surgical staff monitoring activities and assists with interpretation of standards and requirements of external review agencies.

Participates in the development of policies and procedures and assists with the implementation of them. Conducts policy review. Evaluates data for its reliability and validity.

Is the subject matter expert for the facility on measures for VASQIP program performance and instructs hospital staff in principles of VASQIP program and data review.

Attends educational activities and VA continuing education programs to increase knowledge related to surgical quality improvement and Performance Improvement.

Identifies and initiates sharing expertise within and/or external to the organization by leading interdisciplinary groups, ad hoc committees and/or task forces/projects, publishing, teaching formal classes at academic institutions, etc.

Serves as a consultant on Performance Improvement issues to surgical staff members.

Demonstrates effective verbal and written communication skills and behaviors that promote cooperation and teamwork with internal and external customers in a timely manner.

Employs the principles and techniques of group process skillfully and appropriately. Collaborates effectively with all levels of staff within the medical center serving as consultants and mentors.

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