• Develop processes to assess and validate compliance checklists applicable to The Joint Commission standards.
• Analyze and provide accreditation compliance reports, executive summaries, and briefings to the executive staff.
• Develop and implement the execution of facility-wide mock surveys and analyze the results to identify and mandate correction of vulnerabilities.
• Manage the organization’s preparation and report of significant findings related to patient care practices to the Quality Council, Medical Executive Committee (MSEC) and Executive Committee.
• Provide critical support to the Chief Medical Officer to ensure the organization is operated in strict compliance with the Defense Health Agency regulations.
• Ensure data is relevant and meets regulatory requirements for The Joint Commission and DoD compliance with Quality Improvement/Process Improvement program(s).
• Advise department chiefs and other staff on findings of analysis and recommends methods for improving outcomes.
• Serve as the Military Treatment Facility's senior technical expert for the Performance Improvement (PI) program.
• Develop policies and governance to standardize Performance Improvement (PI) procedures and training across the command.
• Facilitate performance improvement activities throughout the organization that includes the planning, developing, directing, organizing and evaluating of improvement initiatives and ongoing measures of organization performance.
• Collaborate with Patient Safety Manager, Risk Manager, Safety Manager, Clinical Operations, Patient Experience/Satisfaction, and Department Chiefs through the strategic planning process to prioritize quality assessment and performance improvement.

Conditions of employment

• Appointment may be subject to a suitability or fitness determination, as determined by a completed background investigation.
• This position requires the incumbent be able to obtain and maintain a determination of eligibility for a Secret security clearance or access for the duration of employment. A background investigation and credit check are required.
• One year trial/probationary period may be required.
• This position has mandatory seasonal Influenza vaccination requirements and is subject to annual seasonal Influenza vaccinations unless otherwise exempted for medical or religious reasons (documentation of exemption must be provided upon hire).
• Immunization screening is required for Hepatitis B immunization. Applicants may be required to show proof of other immunizations depending on the type of position.
• This position requires the incumbent to have Tuberculosis testing.
• Travel to up to 15% may be required to Naval Branch Health Clinics Indian Head, Dahlgren and Joint Base Andrews.

Qualifications

Who May Apply: US Citizens

In order to qualify, you must meet the experience requirements described below. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; student; social). You will receive credit for all qualifying experience, including volunteer experience. Your resume must clearly describe your relevant experience; if qualifying based on education, your transcripts will be required as part of your application. Additional information about transcripts is in this document.

Specialized Experience: One year of specialized experience which includes 1) supporting hospital readiness and accreditation programs in alignment with The Joint Commission standards; 2) collaborating with hospital leadership and clinical staff to identify operational deficiencies and recommend process improvements; 3) interpreting and applying regulatory guidance to ensure compliance with healthcare regulations; and 4) retrieving, analyzing, and interpreting data from electronic health systems to identify trends. This definition of specialized experience is typical of work performed at the next lower grade/level position in the federal service (GS-11).

**Some federal jobs allow you to substitute your education for the required experience in order to qualify. For this job, you must meet the qualification requirement using experience alone-no substitution of education for experience is permitted.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

Once the announcement has closed, a review of your application package (resume, supporting documents, and responses to the questionnaire) will be used to determine whether you meet the qualification requirements listed on this announcement. Please follow all instructions carefully when applying, errors or omissions may affect your eligibility.

If, after reviewing your resume and/or supporting documentation, a determination is made that you have inflated your qualifications and/or experience, you may lose consideration for this position.

Veterans and Military Spouses will be considered along with all other candidates.

The documents you are required to submit vary based on whether or not you are eligible for preference in federal employment. A complete description of preference categories and the associated required documents is in the Applicant Checklist for Public Announcements.

As described above, your complete application includes your resume, your responses to the online questionnaire, and documents which prove your eligibility to apply. If you fail to provide these documents, you will be marked as having an incomplete application package and you will not be considered any further.

1. Your resume:

• Your resume must be two pages or less and must support the specialized experience described in this announcement. Resumes exceeding two pages will be removed from consideration.
• For each relevant work experience, make sure you include the employer's name, job title, start and end dates (include month and year), for qualifications purposes, the number of hours worked per week, and a brief description that show you can perform the tasks at the required level listed in the job announcement. If your resume does not contain this information, your application may be marked as incomplete, and you may not receive consideration for this position.
• Use plain language. Avoid using acronyms and terms that are not easily understood. The hiring agency will not make assumptions about what's in your resume.
• If your resume includes a photograph or other inappropriate material or content, it will not be used to make eligibility and qualification determinations, and you may not be considered for this vacancy.
• For additional information, to include formatting tips, see: What to include in your resume.

• Cover Letter, optional
• Most recent Performance Appraisal, if applicable

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