Compounded Sterile Preparation and Medication Safety Pharmacy Program Manager

The CSP and Medication Safety Program Manager is a licensed pharmacist responsible for the development implementation management and reporting outcomes of the CSP and Medication Safety Program. The Program Manager directs oversees and supervises activities of all assigned operational technical and professional personnel and is the leader for assuring that all USP795 USP797 and USP800 CSP compliance requirements are met in the Sterile Processing and Hazardous Drug Management arenas. Maintenance of all required processes and documentation for completely meeting USP795 USP797 and USP800 are a primary focus of this position. They will develop and implement appropriate procedures oversees and assures facility compliance with USP795 USP797 and USP800 and other applicable laws regulations and standards ensuring competency of personnel and assuring environmental control of all compounding areas.

CSP Program Management

• Ensures CSP and hazardous medications are handled and prepared in accordance with all departmental policies/procedures and all State Federal and other governing body laws and regulations including VAPSHCS policy VHA Directives FDA and DEA regulations Federal and State Law NIOSH USP and TJC standards.
• Establishes CSP Committee as required to meet the VHA directive related to compounded sterile preparations.
• Maintains the CSP and Hazardous Medication program to improve outcomes of patients and to protect healthcare workers.
• Ensures the facility hazardous medication policy is reviewed yearly staff are educated on each new hazardous medication introduced into the workplace and is responsible for annual hazardous medication training of all relevant staff.
• Participates in continuous quality initiatives to assist with the continual improvement of procedures policies and overall performance of the program. Maintains a compounded sterile preparation and hazardous medication quality assurance plan in collaboration with Quality Management and Infection Prevention. Identifies outcome measures to evaluate success of the program and identify opportunities for improvement or expansion.
• Collaborates with additional services including Facilities Management Service Industrial Hygiene Infection Prevention and Environmental Management Services and provides quarterly reports detailing results of any investigations and corrective actions due to failures in microbial monitoring parameters or engineering controls to the Medical Executive Committee and Pentad through the facility VA CSP Advisory Committee.
• Maintains clinical oversight of patients receiving compounded sterile and hazardous medications to ensure safe and effective utilization.
• Promotes Pharmacy Clinical Services philosophy of multidisciplinary teamwork and customer service and to make patient-focused decisions. Encourages pharmacy activities that support the pharmacy mission using established goals and objectives to make critical decisions.
• Collaborates with other pharmacy program managers and supervisors to integrate the Compounded Sterile Preparations and Hazardous Medication Program into the global mission of the department. s.

Medication Safety Program Management:

• Participates as the Pharmacy Clinical (PCS) service line representative for the patient safety committee
• Reviews and assesses compliance with VHA Handbooks USP 797 Standards and EPA regulations and any other accreditation surveys or inspections (e.g. OIG TJC CARF and OSHA). Develops and implements policies as needed to ensure compliance.
• Monitors and reviews medication errors. Reviews data for trends and when systems errors occur works to correct processes.
• Actively conducts surveillance of all adverse drug events reported through the VA ADERS reporting program and Adverse Reaction Tracking System. Surveillance may be performed through screening for abnormal lab values discharge diagnosis and use of antidotes.
• Assists in the quality assurance process for IV infusion smart pumps.
• Assists in the evaluation process of cabinet based dispensing system (e.g. Omnicell) overrides.
• Serves as the pharmacy technical expert on committees and task forces that relate to medication safety (e.g. Root Cause Analysis Focused Review and Process Action Team)

Work Schedule: Monday through Friday 7:00 am - 3:30 pm
Telework: Ad hoc only
Virtual: This is not a virtual position.
Functional Statement #:
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

• 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 ( 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.

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 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.

To qualify for this position applicants must meet all requirements within 30 days of the closing date of this announcement.

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Education
  • Graduate of an Accreditation Council for Pharmacy Education (ACPE) accredited College or School of Pharmacy with a baccalaureate degree in pharmacy (BS Pharmacy) and/or a Doctor of Pharmacy (Pharm.D.) degree. Verification of approved degree programs may be obtained from the Accreditation Council for Pharmacy Education 20 North Clark Street Suite 2500 Chicago Illinois 60602-5109; phone: or through their Web site at: Prior to 2005 ACPE accredited both baccalaureate and Doctor of Pharmacy terminal degree program. Today the sole degree is Doctor of Pharmacy.)
• Graduates of foreign pharmacy degree programs meet the educational requirement if the graduate is able to provide proof of achieving the Foreign Pharmacy Graduate Examination Commission (FPGEC) Certification which includes passing the Foreign Pharmacy Graduate Equivalency Examination (FPGEE) and the Test of English as a Foreign Language Internet-Based Test (TOEFL iBT).

Licensure. Full current and unrestricted license to practice pharmacy in a State Territory Commonwealth of the United States (i.e. Puerto Rico) or the District of Columbia. The pharmacist must maintain current registration if this is a requirement for maintaining full current and unrestricted licensure.

• A pharmacist who has or has ever had any license(s) revoked suspended denied restricted limited or issued/placed in a probationary status may be appointed only in accordance with the provisions in VA Handbook 5005 Part II Chapter 3 section B paragraph 16.
• NOTE: Individuals who have or have had multiple licenses and had any such license revoked for professional misconduct professional incompetence or substandard care or who surrendered such license after receiving written notice of potential termination of such licens e by the State for professional misconduct professional incompetence or substandard care are not eligible for appointment to the position unless such revoked or surrendered license is fully restored (38 U.S.C. 7402(f)). Effective November 30 1999 this is a requirement for employment. This requirement does not apply to licensed pharmacists on VA rolls as of that date provided they maintain continuous appointment and are not disqualified for employment by any subsequent revocations or voluntary surrenders of State license registration or certification.

English Language Proficiency. Pharmacists must be proficient in spoken and written English as required by 38 U.S.C. 7402(d) and 7407(d).

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations:
GS-13 Facility Program Manager.
Experience:

• In addition to the GS-12 requirements must have 1 year of experience equivalent to the next lower grade level.
  • GS-12 Requirements:
    • 1 year of experience equivalent to the next lower grade level or
    • Completion of an ACPE-accredited Pharm.D. program.
    • AND Meet KSAs
      • Knowledge of professional pharmacy practice.
      • Ability to communicate orally and in writing to both patients and health care staff.
      • Knowledge of laws regulations and accreditation standards related to the distribution and control of scheduled and non-scheduled drugs and pharmacy security.
      • Skill in monitoring and assessing the outcome of drug therapies including physical assessment and interpretation of laboratory and other diagnostic parameters.

Pharmacists assigned to this position must demonstrate the following KSAs:

• Ability to communicate orally and in writing to persuade and influence clinical and management decisions.
• Expert understanding of regulatory and quality standards for their program area.
• Ability to solve problems coordinate and organize responsibilities to maximize outcomes in their program area or area of clinical expertise.
• Expert knowledge of a specialized area of clinical pharmacy practice or specialty area of pharmacy.
• Advanced skill in monitoring and assessing the outcome of drug therapies including physical assessment and interpretation of laboratory and other diagnostic parameters.

Preferred Experience:

• Possess extensive experience in managing compounded sterile preparation (CSP) and hazardous medication safety programs within a large complex healthcare setting preferably a Level 1a facility such as VA Puget Sound Health Care System.
• Demonstrate expertise in ensuring compliance with USP795 USP797 and USP800 standards as well as applicable VHA directives and Joint Commission requirements is highly valued.
• Experience leading interdisciplinary teams providing education/training related to CSP and hazardous drugs and implementing quality assurance and performance improvement initiatives is essential.
• A background in pharmacy operations serving as a subject matter expert and contributing to research or patient safety projects within an academic or VA health system environment is strongly preferred.

Reference: For more information on this qualification standard please visit full performance level of this vacancy is GS-13. The actual grade at which an applicant may be selected for this vacancy is GS-13.

Physical Requirements: Heavy lifting 45 pounds and over; Repeated bending (2 hours); Moderate lifting 15-44 pounds; Depth perception; Light lifting under 15 pounds; Ability to distinguish basic colors; Ability to distinguish shades of colors; Hearing (aid may be permitted); Moderate carrying 15-44 pounds; Reaching above shoulder; Near vision correctable at 13 to 16 to Jaeger 1 to 4; Far vision correctable in one eye to 20/20 and to 20/40 in the other; Use of fingers; Both hands required; Standing (6 hours); Mental and emotional stability;

Environmental Factors: Constant noise; Dust; Extensive keyboard/mouse use; Working closely with others and alone; Protracted or irregular hours of work