Registered Nurse - Deputy Director Quality Management

This position is located at the Lebanon VA Medical Center in Lebanon, PA. The Nurse IV Deputy Chief of QM functions as an advisor, administrator, educator, consultant, and mentor who possesses a wide range of experience and leadership ability. Demonstrates performance that is broad enough to improve the care for a group of patients. This position reports directly to the Director, Quality and Patient Safety.

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 IV:

• Scope: Executes leadership that is characterized by substantial and continuous responsibility and accountability for population groups or integrated programs that cross service and/or discipline lines and influence organizational mission and health care.
• Education: Master's degree in Nursing (MSN) and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV; OR Master's 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 III and meets all dimension requirements for Nurse IV; OR a Doctoral degree in nursing and 3 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV; OR a Doctoral degree in a *related field with a BSN and 3 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV. *Note: Foreign education programs/degrees are not creditable as related degrees.
• Dimensions:
  • Leadership. Leads health care delivery by leveraging evidence-based practices, industry-leading research, and innovative care models. Drives a shared vision and successfully leads change to improve performance and attain measurable outcomes at the program or service level.
  • Business Acumen. Transforms health care by implementing new processes, technology, informatics, and data analytics using business models and fundamental concepts of resource management at the program or service level.
  • Inspiring an Industry-Leading Lifestyle. Employs an industry leading, shared decision-making lifestyle. Cultivates a workforce that serves Veterans, families and caregivers of all backgrounds and builds trust, lifestyle competencies and catalyzes dynamic teams at the program or service level.
  • Communication and Relationship Management. Directs the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional organizational values, beliefs and practices at the program or services level.
  • Professional and Social Responsibility. Operationalizes a lifestyle of holistic care, health advocacy and health equity. Applies ethical principles in decision-making at the program or service level. Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans and the community.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: The population of male and female Veterans served ranges from the adult, age 18, to the elderly adult, age 65 and over. This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing, lifting 45 pounds or more, reaching, stretching, and similar activities supporting various weights. Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs. The incumbent must complete annual employee health requirements as a condition of employment. These physical requirements will be consistent with VA Directive Handbook 5019.

Preferred Experience: Experience with VHA Oversight and Accreditation authorities, Supervisory Experience, Experience with policy and procedure review, Experience communicating and consulting with local, VISN, and National Executive/Clinical leaders, skilled in verbal and written communication styles, proficient with Microsoft products and VHA electronic medical record systems.

Responsibilities:

The Deputy Chief of QM is a self-directed nursing professional who supervises QM staff, assesses plans, implements, coordinates, monitors and evaluates the quality and safety of the delivery of care for the organization. Assumes a leadership role in facilitating regulatory compliance for internal and external oversight bodies (i.e., The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), Veterans Health Administration (VHA) Directives and Handbooks, etc.), Occupational Safety and Health Administration (OSHA), Office of the Medical Inspector (OMI), Office of the Inspector General (OIG), and VHA performance measures, supporting performance improvement work, and supporting and guiding the work of committees.

The Deputy Chief of QM ensures that services have systems and processes in place to provide safe, quality care that is consistent with external benchmarks. Leads performance improvement initiatives by identifying quality metrics, trending data, maintaining the quality metric dashboard, and acts as a subject matter expert in data analysis and data display. Consults and acts as a resource to leadership and staff in standards interpretation implementation, patient safety, infection control, risk management, and re-design of processes and structures to improve care outcomes. Develops and implements policy and procedures, collaborates with service departments, and works toward meeting the strategic plan of the organization.

The Deputy Chief of QM oversees monitoring of corrective actions from survey findings and assists services who are performance outliers. Provides oversight for programs such as the Joint Patient Safety Reporting (JPSR), Tort Claims, and Peer Review. Responsible for completing clinical quality reviews, clinical data analysis, and identifying opportunities for improvement. This includes providing clinical and administrative recommendations relative to all Strategic Analytic Improvement Learning (SAIL) outcomes, External Peer Review Program (EPRP) metrics, and driving improvement initiatives within the medical center.

The Deputy Chief of QM collaborates with the Survey Coordinator for the coordination of accreditation readiness activities focused on standards compliance, education of staff on Functional Statement: Nurse IV Last Updated: May 1, 2025 Page 2 standards, VHA requirements, and customer satisfaction for internal and external stakeholders. Influences care outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in unit/program level quality improvement processes and initiatives as well as customer service programs. Leads QM staff through performance evaluations, provide guidance and support, and change management projects.

The Deputy Chief of QM supports all QM work to include but not limited to Accreditation, System Redesign, Infection Prevention, Patient Safety, Risk Management, High Reliability Organization (HRO), and evidence-based practices. Incumbent may be assigned additional duties dependent on department and /or facility need.


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: 7:00 am - 3:30 pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

Salary : $135,505