Facility Program Manager (Quality Program Manager)

The Pharmacy Quality Program Manager serves as a member of Pharmacy Administration and is responsible for developing policies, procedures, and oversight related to the compliance of pharmaceutical compounding and hazardous drug handling. The incumbent oversees quality management and performance improvement initiatives, ensuring adherence to accreditation standards, regulations, directives, and mandates.

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The duties of the Facility Program Manager (Compliance and Quality Program Manager) include but are not limited to:

• Ensuring NAVAHCS has a policy and processes in place to assess and monitor compliance with USP <797> and USP <800> standards for the handling of Compounded Sterile Preparations (CSP) including cleanroom design, environmental controls and monitors, and core competencies of personnel involved in CSP processes.
• Ensuring that the NAVAHCS CSP Advisory Committee reports issues impacting CSP processes to the VISN using processes established by the VISN.
• Developing a written contingency plan that may be activated to obtain CSPs from an alternative source in situations where CSP preparations at the facility need to be suspended because of non-compliance with relevant standards.
• Ensuring hazardous drugs (HD) that are transported, stored, and handled by other health care professionals are appropriately labeled to alert staff to handle the HDs as required by USP <800>.
• Ensuring the pharmacy service has written procedures for compliance with USP <795>, USP <797> and USP <800> standards.
• Maintaining environmental control of the sterile compounding areas.
• Coordinates ongoing, proactive processes to evaluate and improve safe medication management strategies.
• Develops and maintains look alike sound alike (LASA) and high alert medication lists, labeling, and segregation.
• Participates in root-cause analysis of significant medication errors. Examines the systems failures and human factors contributing to medication errors.
• Evaluates, develops, implements and documents quality and performance improvements in the provision of clinical and full-service distributive pharmacy services.
• Ensures and coordinates compliance with accreditation standards [e.g. The Joint Commission (TJC)], federal, state, organizational, and local regulations, directives and mandates and other regulatory agencies (e.g. Office of Investigator General, Drug Enforcement Agency).
• Provides clinical and administrative supervision to NAVAHCS pharmacy residents.
• Oversees the pharmacy residency program and assures proper training pharmacy residents.
• Performs all other duties as assigned.

Work Schedule: Monday through Friday from 08:00AM to 04:30PM; but tours may vary depending on the needs of the service to include rotating days, nights, weekends and/or holidays.
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 0000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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:

• Citizenship. Citizen of the United States: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency. Pharmacists must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
• Education.
  • Graduate of an Accreditation Council for Pharmacy Education (ACPE) accredited College or School of Pharmacy with a baccalaureate degree in pharmacy (BS Pharmacy) and/or a Doctor of Pharmacy (Pharm.D.) degree. Verification of approved degree programs may be obtained from the Accreditation Council for Pharmacy Education, 20 North Clark Street, Suite 2500, Chicago, Illinois 60602-5109; phone: (312) 664-3575, or through their Web site at: http://www.acpe-accredit.org/. (NOTE: Prior to 2005 ACPE accredited both baccalaureate and Doctor of Pharmacy terminal degree program. Today the sole degree is Doctor of Pharmacy.)
  • Graduates of foreign pharmacy degree programs meet the educational requirement if the graduate is able to provide proof of achieving the Foreign Pharmacy Graduate Examination Commission (FPGEC) Certification, which includes passing the Foreign Pharmacy Graduate Equivalency Examination (FPGEE) and the Test of English as a Foreign Language Internet-Based Test (TOEFL iBT)
• Licensure. Full, current and unrestricted license to practice pharmacy in a State, Territory, Commonwealth of the United States (i.e., Puerto Rico), or the District of Columbia. The pharmacist must maintain current registration if this is a requirement for maintaining full, current, and unrestricted licensure. A pharmacist who has, or has ever had, any license(s) revoked, suspended, denied, restricted, limited, or issued/placed in a probationary status may be appointed only in accordance with the provisions in VA Handbook 5005, Part II, Chapter 3, section B, paragraph 16.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

Facility Program Manager, GS-13
Experience: At least one (1) year of experience equivalent to the next lower grade level (GS-12) which demonstrates the Knowledge, Skills, and Abilities (KSAs) and other characteristics related to the duties of the position to be filled. KSAs described at the next lower grade level include: knowledge of professional pharmacy practice, ability to communicate orally and in writing to both patients and health care staff, knowledge of laws, regulations, and accreditation standards related to the distribution and control of scheduled and non-scheduled drugs and pharmacy security, and skill in monitoring and assessing the outcome of drug therapies, including physical assessment and interpretation of laboratory and other diagnostic parameters.

In addition to the experience mentioned above, the candidate must also demonstrate all of the following KSAs:

• Ability to communicate orally and in writing to persuade and influence clinical and management decisions.
• Expert understanding of regulatory and quality standards for their program area.
• Ability to solve problems, coordinate and organize responsibilities to maximize outcomes in their program area or area of clinical expertise.
• Expert knowledge of a specialized area of clinical pharmacy practice or specialty area of pharmacy.
• Advanced skill in monitoring and assessing the outcome of drug therapies, including physical assessment and interpretation of laboratory and other diagnostic parameters.

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

The full performance level of this vacancy is GS-13.

Physical Requirements: The work requires regular and recurring physical exertion, involving standing/sitting for prolonged periods of time, lifting/carrying of pharmaceutical supplies weighing up to 50 lbs., and bending/stooping. The work may entail repetitive wrist movement while using various size syringes, vial cap removal, and typing. Normal safety precautions and practices are required for working in a healthcare environment. For additional guidance, please refer to VA Directive and Handbook 5019, Employee Occupational Health Service for requirements.

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.