Job Specification Details

Administrative and policy development work for the Vermont Psychiatric Care Hospital or the Vermont Veterans’ Home, involving the management and implementation of ongoing, facility wide, data driven quality assessment and performance improvement program. Develop and maintain systems which will ensure successful program design and quality delivery of services. Duties include representing the facility as primary point of contact with surveyors and other representatives of state and federal regulatory agencies. Develop plans of correction in response to regulatory findings; oversee corrections, track and communicate results. Reports directly to Chief Executive Officer or the Nursing Services Director. Majority of work is independently determined based on review and analysis of current trends, hospital/facility processes and events, and interactions with regulatory agencies. Specific projects as assigned by the CEO or the Nursing Services Director.

Works cooperatively with internal and external partners in all aspects of duties.

Gather and analyze data to identify trends, plan interventions and corrections as necessary, track improvement plans for effectiveness and accomplishment of measurable improvement outcomes

Design and manage facility system of adverse patient/resident, employee, and medication related event reporting, perform analyses, develop and manage corrective responses

Provide educational feedback to nurses and physicians related to quality concerns.

Manage all facility policy and procedure processes and manuals; manage facility utilization review process

Undertake root cause analyses and follow up responses as necessary

Manage patient/resident grievance process

Manage and facilitate leadership review, analysis, and necessary corrective responses related to emergency involuntary procedures and other related patient and staff safety concerns.

Interact with patients/residents during follow-up investigations and design of facility responses to patient/resident grievances or investigating and developing corrective actions following adverse events and near-misses

Collaborate with all facility management and non-management staff to monitor, investigate, analyze, and guide corrective actions intended to improve facility processes and systems.

Performs other related duties as required.

Duties are performed primarily in office settings. Considerable tact is required for dealing with internal and external partners. Some pressure from deadlines may be experienced.

Extensive knowledge of quality improvement principles and practices.

Extensive knowledge of evaluation methodology and best practice development strategies

Ability to prepare required reports and provide interpretation and explanation of reports

Ability to understand and apply evaluation tools

Ability to proficiently work with databases, spreadsheets, and other programs for data analysis.

Considerable knowledge of hospital/facility systems and applicable best practices.

Extensive knowledge of applicable complex federal, state, and regulatory standards and ability to interpret and apply such standards.

Ability to communicate effectively in written and oral forms.

Ability to prioritize and manage complex projects.

Ability to identify data to be collected.

Ability to analyze data and coordinate with hospital/facility operations to ensure data informs practice.

Ability to establish and maintain effective working relationships with internal and external staff and agencies.

Ability to climb stairs, lift (at maximum level per current OSHA standards), stoop, crouch, kneel or squat repetitively.

Possession of (or eligible for) licensure as a Registered Nurse (RN) in Vermont OR eligible to practice in the state of Vermont via a multi-state license AND five (5) years or more of professional nursing experience INCLUDING two (2) years or more of hospital or facility quality management experience.

For position at the Vermont Veterans’ Home, QAPI (Quality Assurance Performance Improvement) certification must be obtained within 6 months of hire.

Master of Science in Nursing (MSN).

NOTE: Must maintain Vermont licensure as a Registered Nurse OR eligible to practice in the state of Vermont via a multi-state license as a condition of employment.

Candidates must pass any level of background investigation applicable to the position. In accordance with applicable hiring standards, fingerprint supported criminal record checks, adult and child abuse registry checks, the Office of Inspector General exclusion database, and motor vehicle driving record checks, as appropriate to the position under recruitment, will be conducted on candidates, with the exception of those who are current classified state employees seeking transfer, promotion, or demotion into a classified position or are persons exercising re-employment (RIF) rights.

For positions at the Vermont Veterans' Home: Any person who has had a charge of abuse, neglect or exploitation substantiated against him or her is not eligible under the Vermont Veterans’ Home licensing requirements. Candidates must pass any level of background investigation applicable to the position, including Vermont and national criminal record checks, adult and child abuse registry checks, the Office of Inspector General exclusion database, and motor vehicle driving record checks where applicable.