Registered Nurse - Performance Measures Coordinator Quality Nurse

Performance Measures Coordinator Quality (PMC) Nurse is responsible for utilizing nursing process and practice principles to ensure delivery of safe high quality, patient­ centered care. The Nurse serves as a clinical and administrative resource responsible for supporting delivery of safe, high-quality, data-driven care across the Veterans Health Care System of the Ozarks and is strategically aligned in the Quality and Patient Safety Service, directly reporting to the Medical Center Director.

EDUCATION: RESPONSIBILITIES: The Performance Measures Coordinator functions as the Strategic Analytics for Improvement and Learning (SAIL) Coordinator, and the facility External Peer Review Program (EPRP) Liaison. The PMC reviews, compiles and validates data required for mandatory reporting and internal quality oversight ensuring data accuracy for SAIL, EPRP, Inpatient Evaluation Center {IPEC), MISSION Act Quality Standards Tracking Report, Combined Measure Master (CMM), and other enterprise dashboards. Familiarity with the purpose and functions of external review organizations and the impact performance measures and performance metrics have on outcomes of reviews (e.g. The Joint Commission (TJC), Veteran Integrated Service Network

{VISN) Clinical Reviews, EPRP, CMS Care Compare, and Facility Performance Plans). Other duties include but not limited to the following:

Demonstrates leadership, experience, and creative approaches to improvement in quality of­ care outcomes.

Responsible for the documented outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level.

Collects data, monitors compliance with relevant policies, directives, and standards, provides reports detailing trends, implementing, modifying, and administering, a comprehensive performance improvement program area. They participate in several facility councils, committees, and workgroups.

Executes the position responsibilities demonstrating effective leadership, detailed planning, professional communication, creative and innovative approaches to the improvement of quality and patient safety.

Performs duties directly contributing to high quality and safe patient care within the Veterans Health Administration(VHA). The PMC directly supports facility leadership in areas of planning, organization, development, direction, and evaluation of the performance improvement program within the facility.

Works closely with the Systems Redesign Coordinator and High-Reliability Organization (HRO) Lead to ensure policies and procedures are developed to support the principles of continuous process improvement and HRO.

Serves as Chairperson of the SAIL Committee fulfilling all associated responsibilities of coordination of committee agendas, meetings, action plans, and minutes.

Serves as the Health Care System's authoritative consultant on all Performance Measures and Performance Metrics that impact organizational outcomes.

Monitors national, VISN, and local performance dashboards and measure sets, identifying trends, variation, and areas of vulnerability requiring leadership attention.

Interprets complex regulatory, accreditation, and policy requirements related to performance measurement and ensures the accurate application of standards.

Conducts detailed analysis of clinical, operational, and administrative data to guide decision-making by Senior Leadership and Service Chiefs.

Provides expert guidance to Senior Leadership and Service Chiefs on compliance with mandated performance standards.

Advises facility leaders on risks, opportunities, and strategic actions required to improve performance and maintain system reliability.

Participates in executive-level meetings and committees, presenting data and recommending actions that support high-reliability transformation.

Leads and supports systemwide improvement initiatives by integrating performance measure data with quality improvement methodology.

Conducts education and coaching for staff, supervisors, and managers on performance improvement tools, measurement systems, and interpretation of results.

Assesses organizational workflow, identifies barriers to achieving targets, and collaborates with services to redesign processes.

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: Monday - Friday, 7:30am - 4:00pm, 7:00am -3:30pm, or 8:00am - 4:30pm

Telework: Available, per supervisor's discretion.

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not authorized

Permanent Change of Station (PCS) : Not authorized 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.

Preferred Experience:

Demonstrated experience serving in performance improvement role in a healthcare system, with responsibility for monitoring, analyzing and reporting on organizational performance metrics.

Proficiency performing data validation, analysis and interpretation.

Prior experience collaborating with interdisciplinary leaders and services (e.g., Nursing, Primary Care, Specialty Care, Preventive Medicine, Quality & Patient Safety, System Redesign, High Reliability).

Demonstrated skill preparing detailed reports, action plans, meeting documentation, and performance summaries for internal and external stakeholders.

Experience participating on and/or leading organizational committees.

Proven ability to educate staff on performance improvement tools, measurement systems, audit reviews and data interpretation.

Experience evaluating and redesigning workflows to improve compliance with policies, directives, and performance targets

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/12972299 .

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

Physical Requirements: This position requires heavy lifting and carrying 45 pounds and over, straight pulling and pushing 1 hour, reaching above shoulder, use of fingers, both hands required, walking and standing 7 hours, kneeling .5 hour, repeated bending 7 hours, both legs required, operation of crane, truck, tractor, or motor vehicle, ability for rapid mental and muscular coordination simultaneously, 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, ability to distinguish basic colors, ability to distinguish shades of colors, hearing without aid, mental and emotional stability, working with detergents and antiseptic solutions. SALARY: QuantitativeValue EMPLOYMENT TYPE: Other