Deputy Chief of Quality and Patient Safety

Summary

The Deputy Chief of Quality and Patient Safety functions as an administrator, advisor, educator, consultant, and mentor responsible for coordinating and evaluating quality and patient safety programs across multiple services and disciplines. The incumbent collaborates with medical center leadership, interdisciplinary healthcare professionals, and internal and external stakeholders to improve clinical outcomes, strengthen organizational performance, and advance the medical center's goals.

Duties

• Duties of the Deputy Chief of Quality and Patient Safety include, but are not limited to: Provides executive-level nursing leadership, oversight, and coordination of organizational Quality and Patient Safety programs across multiple services and disciplines. Supervises Quality and Patient Safety personnel, including providing guidance, performance evaluations, professional development, and support for organizational change and improvement initiatives. Assesses, plans, implements, coordinates, monitors, and evaluates quality management and patient safety programs to promote safe, effective, and Veteran-centered healthcare delivery. Provides leadership in maintaining compliance with applicable VHA directives, regulatory requirements, accreditation standards, and organizational policies and procedures. Facilitates organizational accreditation readiness activities in collaboration with the Survey Coordinator, including standards compliance, staff education, and monitoring of corrective actions. 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). Oversees monitoring and follow-up of corrective actions resulting from regulatory surveys, accreditation findings, and identified performance deficiencies. Coordinates and provides oversight of quality and patient safety activities, including Joint Patient Safety Reporting (JPSR), tort claims, and peer review programs. Conducts and oversees clinical quality reviews, clinical data analysis, and evaluations of healthcare processes to identify opportunities for improving patient safety and clinical outcomes. Monitors organizational performance measures, including Strategic Analytics for Improvement and Learning (SAIL) outcomes and External Peer Review Program (EPRP) metrics. Identifies quality indicators, analyzes performance trends, and maintains organizational quality dashboards to support data-driven decision-making and performance improvement. Serves as a subject matter expert in clinical quality data analysis, interpretation, presentation, and utilization to improve healthcare outcomes. Provides consultation and guidance to medical center leadership and staff regarding standards interpretation, patient safety, infection prevention, risk management, and process redesign. Develops, implements, and evaluates policies, procedures, and clinical processes designed to improve patient safety, quality of care, and organizational performance. Leads performance improvement initiatives by identifying gaps in healthcare delivery, evaluating organizational processes, and implementing evidence-based corrective actions. Collaborates with interdisciplinary healthcare teams and service leaders to develop and implement sustainable improvements in patient care and operational efficiency. Supports Quality and Patient Safety programs, including accreditation, system redesign, infection prevention, patient safety, risk management, High Reliability Organization initiatives, and evidence-based practices. Provides leadership in strategic planning and aligns quality improvement initiatives, organizational resources, and performance measures with medical center goals. Promotes effective utilization of organizational resources through evaluation of clinical and nonclinical operations, business processes, and performance outcomes. Participates in and provides leadership to medical center committees, councils, workgroups, and interdisciplinary improvement initiatives. Facilitates communication and collaboration among clinical and administrative staff to promote organizational accountability, teamwork, and continuous improvement. Provides education, consultation, mentoring, and professional development opportunities to healthcare staff regarding quality management,…

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. The following Scope, Education and Dimension criteria must be met to qualify for Nurse V: Scope: Practice of an executive nature, comprised of complex leadership and administrative components, associated with critical health care issues and activities that drive meeting the organizational mission, health care and policy. Education: Master's degree in Nursing (MSN) and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR Master's degree in a *related field with a BSN and 5 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in Nursing and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V; OR a Doctoral degree in a *related field with a BSN and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse IV and meets all dimension requirements for Nurse V. *Note: Foreign education programs/degrees are not creditable as related degrees. Dimension Requirements: Leadership. Establishes the strategic direction for health care delivery, evidence-based practices, industry-leading research, and innovative care models. Creates a sh…