The registered nurse is directly responsible to the Chief, Quality, Performance and Patient Safety. The registered nurse is knowledgeable of patient care processes and has exceptional expertise in objective analysis, presenting factual, comprehensive summaries and facilitating satisfactory resolutions for the organization. The nurse has excellent interpersonal skills, discretion, and integrity. This position serves as the designated EPRP Liaison/Coordinator and in that capacity has primary responsibility for facility EPRP program oversight and coordination responsibilities. The EPRP Liaison implements this program in accordance with VHA, Network and facility requirements. The specifics of this program are outlined in the External Peer Review Program Guide on the VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID) Office of Performance Measurement (10A8). In this role he/she is responsible for: Requesting/maintaining access to Quality Insight VHA EPRP Secure site Orienting the Abstractor to the VAMC staff and process Assisting in gaining local computer access Assisting in providing medical record information not found in CPRS Scheduling with Abstractor any onsite/virtual visits as needed Negotiates an annual Data Accountability agreement with the EPRP abstractor Monthly review of Data Accountability Checklists (DACs) within the 4-day timeframe and providing any missing information, to support that the record meets the measurement requirement to the Abstractor for any changes DAC reconciliation process with Abstractor Understanding and following the reconsideration process when additional supporting documentation is found within the allocated timeframe or when the facility disagrees with the data the Abstractor has entered Organizing and overseeing Exit conference Communication of changes to current, new or deleted metrics to the subject matter experts Facilitate and/or lead Process improvement teams to address any gaps in performance Works closely with the subject matter experts to develop actions plans to improve and meet the metrics within the EPRP program Monitor implementation of actions plans and provide appropriate feedback to subject matter experts and leadership team Provides a data resource for multiple VHA reporting systems, (i.e.) Combined Measure Master report (CMM), Combine Composite Report (CCR), Quarterly Composite Report (QCR), HEDIS report, Gender report, CBOC report and electronic Quality Measurement (eQM) And other duties as assigned This clinical analyst also routinely provides clinical review, analysis and facilitate resolution for performance measures, SAIL and the Director's Performance Plan. In this role, he/she is responsible for: Collaborating with other facilities within and outside the VISN to obtain and share "Best Practices" on Performance metrics Disseminate changes to the SAIL report to the facility subject matter experts and the leadership team Increasing awareness of the SAIL report to the front-line staff and how they may impact individual metrics Facilitate and/or lead Process Improvement teams to address gaps in performance Trending and analyzing quarterly data from SAIL report and reporting this information to the leadership team Facilitates and/or leads implementation of the Director's Performance Plan Organizing and overseeing Internal and VISN9 Operations/Performance review calls Collecting and maintaining facility response for the Director's Performance Plan on VISN9 share point site Keeping facility and leadership abreast of any changes that occur to the Director's Performance plan Assisting Performance Champions in the development and sustainment of specific actions plans related to the Performance Pla Serving on designated Committees as the Quality Department representative The incumbent has a working knowledge sufficient to provide support as required to the patient safety programs. The incumbent supports overall external review program readiness (e.g. TJC, CRR, OIG CHIP, etc.) and performance improvement and is responsible for timely completion of special project assignments from the Chief, Quality and/or Quad members. Direct care responsibilities are limited to those consistent with his/her nursing competencies and assigned by the Quad and/or Chief, Quality, Performance & Patient Safety. The registered nurse is accountable and responsible for possessing the knowledge and skills to properly use equipment and maintain clinical and technical skills applicable to the area of assignment. The registered nurse is also responsible for maintaining general competency in: Quality Improvement; Systems Redesign/Lean Accreditation Readiness; Data Management; Risk Management; Utilization Management; and Patient Safety Pay Scale: NF23 Work Schedule: Monday - Friday 8:00 am - 4:30 pm Telework: Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.