Supervisory Health System Specialist

The Chief of Quality Management serves as the facility lead for quality management, performance improvement, systems redesign, and related quality oversight programs. The position reports to the Medical Center Director and has oversight of Continuous Readiness, Utilization Management, Risk Management, Patient Safety, External Peer Review (EDRP), Systems Redesign, VASQIP, and Infection Control.

• Quality and Compliance - 50 % Supervises and provides administrative and program oversight for risk management, patient safety, systems redesign, infection control, external peer review, and related quality management programs as assigned by the Director. Coordinates the integrated relationship of these programs to each other and with the organization as a whole to minimize duplication and clarify respective functions.
• Monitors the status of Quality Management programs and related initiatives affecting patient care quality and regulatory compliance. Monitors areas related to improving the quality of care and ensures effective systems are in place. Develops procedures to all administrative and clinical committees and service meetings
• Ensures continuous readiness and compliance for various external site reviews, including The Joint Commission (TJC), Office of Inspector General (OIG), Commission on Accreditation of Rehabilitation Facilities (CARF), Community Living Center (CLC) Survey, and Office of Medical Inspector. Collaborates with the chairs of key system committees to develop compliance review schedules.
• Collaborates with executive leaders in the development and implementation of quality management policies and performance improvement strategies. Analyzes services provided and organizational resources to determine alternative resource allocations and make recommendations to executive leadership.
• Provides performance improvement direction and advice to various system committees and follows up on recommendations to VAEKHCS executive boards and committees to ensure the timely resolution of identified problems. Prepares performance improvement agendas and briefs for the ELT, highlighting issues and progress.
• Provides oversight for major performance improvement projects, collaborating with VAEKHCS management to ensure full implementation of recommendations, as well as VHA mandates. Educates and trains staff on performance improvement methodology and evaluation.
• Advises and collaborates with service leaders regarding the development, implementation, evaluation, and improvement of clinical and administrative programs. Consults with service chiefs, committee chairpersons, and program managers to develop and execute service and program strategies that align with VAEKHCS Strategic Plan and VHA Performance Measures.
• Directs the QM Service, responsible for multiple programs focused on monitoring quality and performance metrics and performing studies to analyze and improve operations. Programs include Continuous Readiness, Utilization Management, Risk Management, Patient Safety, External Peer Review (EDRP), Systems Redesign, VASQIP, and Infection Control. The mission of the service line is a combination of complex administrative and technical evaluations and professional collaboration, oversight, and analysis.
• The program directly affects accreditation readiness, regulatory compliance, patient safety oversight, and organizational performance. Program findings and recommendations support executive leadership decisions regarding corrective actions and continuous improvement initiatives.
• The incumbent provides administrative and technical supervision to 15 employees working in the QM service. The incumbent is responsible for the administrative supervision of ten (10) Title 38 employees.
• The incumbent plans work to be accomplished by subordinates, sets and adjusts short-term priorities, and prepares schedules for completion of work; Assigns work to subordinates based on priorities, selective consideration of the difficulty and requirements of assignments, and the capabilities of employees; Evaluates work performance of subordinates; Gives advice, counsel, or instruction to employees on both work and administrative matters; Interviews candidates for positions, selecting, promoting or reassigning candidates to such positions; Hears and resolves complaints from employees, only referring more serious unresolved grievances and complaints to the Health System Director; Effects minor disciplinary measures, such as warnings and reprimands, recommending other actions in more serious cases; Identifies developmental and training needs of employees, providing for and arranging for needed development and training; Identifies ways to improve production or increase the quality of work directed; Develops performance standards; Approves and disapproves annual and sick leave.

• IOR Specialized Experience: Do you possess at least one (1) full year of specialized experience equivalent to at least the next lower grade level (GS-12) in the Federal Service, that is directly related to the work of the position and has equipped you with the particular knowledge, skills and abilities to successfully perform the duties as a Health System Specialist Qualifying specialized experience is defined as progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following:
  • Missions, organizations, programs, and requirements of health care delivery systems;
  • Regulations and standards of various regulatory and credentialing groups; and
  • Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. OR,

• Assignments providing a knowledge of basic health system administration philosophies, practices, and procedures, and basic government administrative policies and requirements;
• Practical assignments providing an opportunity to apply health system administration skills and principles (as the individual progresses, work assignments must be characteristic of the grade level to which he or she is assigned); and
• Oversight by an experienced health system administrator with periodic evaluation of the individual's progress and appropriate adjustment of the training program.

• Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-12 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following:
  • Comprehensive knowledge of quality management principles, process improvement methodologies, performance measurement techniques, and compliance programs. Comprehensive knowledge of the health care organization, medical staff structure, medical school complexities and structures, regulatory and accreditation requirements, and experience with the clinical and administrative aspects of health care delivery systems, facilities, and operations. Knowledge of healthcare operations and quality management principles sufficient to identify and resolve complex administrative and programmatic issues. Strategic planning, program management, and organizational performance improvement principles sufficient to develop, implement, and evaluate short and long range quality management initiatives. Analytical and statistical methodologies sufficient to evaluate performance data, identify trends, assess program effectiveness, and support quality improvement decision making. Research methodilogies and interpret and evaluate data obtained through studies, minutes of meetings, and statistical reports that provide independent recommendations. HR and personnel policies experience in a healthcare delivery system to approve and initiate personnel actions, approve leave and awards, recruit and select new hires, manage labor and employee relations issues, and evaluate and develop employees.

• You must be a U.S. citizen to apply for this job
• Subject to a background/suitability investigation
• Selective Service Registration is required for males born after 12/31/1959
• A complete application package; Resume, Transcripts, etc. is required
• 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.

• 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