Registered Nurse (Quality Management)

The Quality Management Nurse for Surgical Service plays a critical role in monitoring analyzing and improving the quality of surgical care provided to Veterans. This position ensures compliance with VHA policies patient safety standards and national quality initiatives through data-driven evaluation and collaboration with clinical leadership.

Duties include but are not limited to:

• Conduct daily reviews of surgical admissions consults and operating room cases to identify complications readmissions and occurrences meeting VASQIP criteria.
• Track and report Patient Safety Indicators (PSIs) and prepare cases for Peer Review and Quality Improvement (QI) conferences.
• Develop and maintain comprehensive quality reports including trends in readmissions complications surgical site infections and mortality audits.
• Collaborate with Infection Control Patient Safety Risk Management and coding teams to validate data and implement corrective actions.
• Participate in EPRP audits SAIL data analysis and post-discharge adverse event reviews to identify improvement opportunities.
• Ensure compliance with pre- and post-operative documentation standards; provide timely feedback to surgical teams.
• Prepare ad hoc reports and respond to urgent data requests from the Chief of Surgical Service.
• Serve as an active member on key committees including Infection Control Patient Safety Surgical Workgroup Operative and Invasive Procedures and Accreditation.
• Provide training and education to new surgical attendings and mid-level providers on quality management processes.
• Maintain strict confidentiality and deliver accurate timely information to support leadership decision-making.
• Serve as a resource for interpreting and communicating VACO and Medical Center policies.
• Lead and facilitate interdisciplinary meetings to address quality concerns and implement action plans.
• Develop and maintain continuous monitoring and reporting systems for patient care quality.
• Evaluate current practices using CQI tools and formulate criteria for care evaluation.
• Collaborate with Service Chiefs and management to analyze findings implement changes and assess effectiveness.
• Work closely with VASQIP nurses to reconcile complications and mortality data.
• Coordinate with the Medical Center Quality Office on surgical quality issues and peer reviews.
• Partner with the Chief Resident in Surgery to advance quality and safety initiatives
• Participates in the surgical workgroup meetings and prepare the death audits for discussion.
• Other duties as assigned.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards

Pay: Competitive salary regular salary increases potential for performance awards
Paid Time Off: 50 days of paid time off per year (26 days of annual leave 13 days of sick leave 11 paid Federal holidays per year)
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)Licensure: 1 full and unrestricted license from any US State or territory

Work Schedule: Full-time 7am - 3:30pm
Telework: Not available.
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized.

• This position is in the Excepted Service
• Current and former Federal employees must submit copies of their most recent SF-50 (Notice of Personnel Action). The SF-50 must identify the position title series grade step tenure and type of service (Competitive or Excepted). In some cases more than one SF-50 may be required to show a higher grade previously held.
• Narrative responses to the knowledge skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.

Conditions of employment

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• 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.
• 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 ( Effective May 7 2025 drivers 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.
• May be subject to satisfactory completion of our credentialing process.

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

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 masters level bridge program in nursing who have completed coursework equivalent to a bachelors 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.

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: I Level IDelivers 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 IIDemonstrates 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 IIIDemonstrates 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 Masters degree in nursing (MSN) and no additional professional nursing experience; OR a Masters degree in a *related field with a BSN and no additional professional nursing experience.Nurse IIDemonstrates 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 Masters 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 IIIExecutes 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 Masters 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: For more information on this qualification standard please visit Requirements: All applicants must be physically able to satisfactorily perform the duties of the position. A pre-placement physical examination shall be completed prior to appointment.