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The Surgical Quality Care Nurse coordinates the Veterans Administration Surgical Quality Improvement Program (VASQIP). The RN will carefully monitor and maintain VASQIP registry data, help maintain surgical quality metrics for the facility, communicate regularly and work with clinical coordinators, providers, and administrators on the Surgical Service. Additional clinical responsibilities will be assigned based on clinical needs of the service. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Preferred Experience: BSN 2 years experience of Acute Care Experience 2 years Quality Manage Experience Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: Walking, bending, stooping, and some lifting in the direct care of patients. There may also be extended periods of sitting. ["VA offers a comprehensive total rewards package: VA Nurse Total Rewards Major Duties: Understand National Surgery Office quality, safety, access, productivity, satisfaction, operating room efficiency metrics. Complete Surgical Risk Assessments by reviewing medical records and clinical screening. Data maintenance and compilation; report to Director of Specialty Service on quality, patient satisfaction, utilization, efficiency metrics of providers, clinics, and operating room. Report to Director of Internal Medicine on readmissions, mortality and length of stay metrics. Work with operating room, nursing, clinic staff and providers to increase quality, efficiency, and utilization, educate on VASQIP parameters and NSO data points Work with other surgical administration staff in overseeing quality and efficiency of care provided to Veterans through providers on the service Complete Quality of Care reviews and occurrence screens. Track, analyze, and trend process activities in patient care and organizational functions. Manage/participate in processes related to root cause analysis actions, peer review actions, process actions, LEAN actions, External Peer Review Program (EPRP) monitors, Inpatient Evaluation Center (IPEC) monitors, Strategic Analytics for Improvement and Learning (SAIL) data, tracers, chart reviews, and environment of care surveillance and employee surveys. Work in collaboration with the Accreditation Coordinator for tracers and chart reviews. Assists in developing Quality Improvement processes to meet the expectations of The Joint Commission (TJC), VHA Headquarters, Office of the Medical Inspector (OMI), Office of the Inspector General (OIG), and other organizations. The ability to analyze the data and identify trends, make recommendations, and facilitate process improvements. Designs, implements, and maintains a system for analyzing, trending, and reporting Quality Management data; like code blues, rapid responses, blood transfusions and strokes. Maintains all confidentiality regulations. Analyses the clinical contents of medical records and associated documents, in terms of quality and appropriateness of clinical care issues, such as adherence to or deviation from accepted practice guidelines, standards or procedures. Monitors assigned services, clinical programs and assigned committees for compliance with policies and regulatory guidelines, assuring that findings are utilized to modify and or improve their performance improvement plan and meet the program or committee goals and objectives. Initiates focus reviews, studies and other projects, as indicated in response to identification of areas in need of improvement and delivery of service or care. Undertakes special projects related to Quality Management. Performs other related duties as assigned Work Schedule: Mon - Fri. 7:30am - 4:00pm\nTelework: Available\nVirtual: This is not a virtual position.\nRelocation/Recruitment Incentives: Authorized\nFinancial Disclosure Report: Not required Paid Time Off: 26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)\nRetirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA\nInsurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)\nLicensure: 1 full and unrestricted license from any US State or territory"]