NURSE (ADMIN), Tacoma, WA

At Madigan you will practice alongside civilian and military health care experts and experience unique professional opportunties. Our staff serves by caring for our military but are not subject to military requirements. We operate within safe staffing standards - giving you time to provide exceptional care. 

Located in the beautiful Pacific Northwest on the Puget Sound, in Washington State, Joint Base Lewis-McChord (JBLM) is near the city of Lakewood, 10 minutes from Tacoma and 20 minutes from Olympia, the state capitol. JBLM is situated in a key location along Interstate 5, allowing easy access to Seattle, Tacoma, and the welcoming neighboring communities. Although the Army and Air Force missions have changed over the years, one thing has not changed—the natural setting of the base. Majestic Mount Rainier looms on the horizon, towering over the other peaks of the Cascade Range. From the mountains to the deep waters of Puget Sound and the Pacific Ocean, the local areas abound in natural beauty and outdoor recreation opportunities. Camping, hunting, fishing, hiking, boating and new sports are a way of life in Washington State.

Working for the Department of Defense comes with an abundance of benefits and perks to include competitive compensation packages, paid-time off, medical benefits, student loan repayments, and retirement package with Thrift Savings Plan to include matching employer contributions. For more information, please visit the following link: https://www.usajobs.gov/Help/working-in-government/benefits/

POSITION DUTIES:

The Joint Commission (TJC) is the accrediting agency for all Department of Defense (DOD) hospitals and clinics. TJC surveys both military and civilian organizations. Accreditation by TJC is a mark of quality and professionalism. This administrative nurse position serves as the subject matter expert and primary coordinator for Joint Commission readiness and sustainment. Position requirements include: staying current with all TJC standards, educating facility staff on TJC standards, and preparing the medical facility for TJC accreditation surveys. Acts as a resource person to the medical staff, hospital staff and administration by interpreting TJC Standards. This scope of responsibility requires intensive analysis of clinical processes, utilizing clinical nursing judgment and oversees organization-wide clinical performance improvement efforts, focusing on systems and processes.

MAJOR DUTIES:

1. As the TJC Continuous Compliance Coordinator/Performance Improvement Manager, the main function is ensuring optimal compliance with accreditation and staying abreast of current applicable Joint Commission, State, and Federal standards. Communicates changes that occur in those standards by acquiring information updates from The Joint Commission, other regulatory agencies, professional journals, societies, and applicable software. Attends or arranges for staff members to attend conferences and seminars addressing applicable standards as they relate to the healthcare industry. Serves as a subject matter expert for Joint Commission standards and assists with the development of facility policies and procedures to ensure compliance with standards. Develops and implements tools that measure the compliance and serve as consultant to develop actions plans to resolve identified challenges and problems that may result identified noncompliance findings. Gathers data from multiple locations within the organization and from multiple data systems to aggregate data sets, analyze and provide detailed reports to the hospital leadership. Works in coordination with personnel responsible for performance improvement, patient safety, and risk management programs. Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care and workflow processes. Assesses all clinical and administrative health care delivery processes to determine compliance with TJC standards. Responsible for the development coordination, facilitation, documentation, analysis and evaluation of short and long range plans and programs relating to TJC standards. Recommends changes and educates staff, oversees the tracer team program and conducts system tracers to evaluate the delivery and support of health care is IAW established organization policies and procedures. This scope of responsibility requires intensive analysis of clinical processes, utilizing clinical nursing judgment. 

a. Maintains a thorough, working knowledge of current philosophies and standards as they relate to the health care industry. Remains abreast of current regulations and directives pertaining to various aspects of health care management that are relevant to TJC Standards. Monitors and evaluates overall progress of the TJC Continuous Compliance Program for MAMC in accomplishing stated goals, ensuring that required resources are utilized in an efficient manner in accomplishing stated goals. Proposes new policies or procedures where necessary to resolve significant management programs. Reviews the TJC Continuous Readiness Program annually to incorporate both long and short term program goals, purpose, objectives, components, organization, responsibilities, scope, procedures, evaluation and definitions. Ensures total integration and regulatory compliance by overseeing the coordination of each program element.

b. Serves as MAMC’s primary authority regarding TJC Continuous Compliance Program. Serves as consultant and advisor to the executive management of the Medical Center to include the Commander, Deputy Commander for Administration (DCA), Deputy Commander for Clinical Services (DCCS), Deputy Commander for Nursing (DCN), Department Chiefs, Services, and activities tasked with TJC responsibilities. Using advanced nursing skills provides assistance and advice concerning the development and improvement of departmental and/or services TJC compliance plans and clinical metrics. Using advanced clinical nursing skills analyzes and provides recommendations for improving efficiency and quality for Departments and Committees through standardization or introduction of new methodologies to conduct TJC related processes, functions, or studies. Proposes policies to improve and/or standardize procedures for groups and/or departments conducting similar TJC functions. Using clinical nursing experience and skill sets, facilitates collaborative and integrated performance improvement activities and TJC Continuous Compliance Program among departments and disciplines throughout the organization. Acts as facilitator for the hospital’s Performance Improvement Update. Provides assistance and advice concerning the development and improvement of TJC implementation processes. Monitors MAMC’s Performance Improvement and Joint Commission programs and activities to ensure that they are ongoing, consistent with continuous quality improvement, appropriately integrated with related programs, properly documented and in full compliance with regulatory guidelines and the Command philosophy. Assists in problem assessment, process evaluation, ensure resolution and follow-up of issues affecting the delivery of quality care.

c. Functions as liaison with local, state and national organizations to promote rapport with external agencies and to bring current information to MAMC. These organizations include the Joint Commission, Office of the Surgeon General, U.S. Army Medical Center, medical treatment facilities in the MAMC region, and Army, Navy and Air Force facilities throughout the world. These direct contacts permit a central reference point in each medical treatment facility to act on problems and answer to inquiries pertaining to the quality and appropriateness of care, Joint Commission, and credentials.

d. Operates a personal computer to input, store, retrieve and manipulate data. Uses various software programs to create data base files and prepare reports using graphs, databases, data analysis tools and narrative summaries for ongoing documentation. Designs and finalizes completed reports.

2. Develops and oversees the Tracer Methodology Program and disseminates information and implements educational classes covering Joint Commission standards for all hospital staff. Employee maintains a good working relationship with administration and department chiefs; works with chiefs to ensure Joint Commission compliance in each department and division; communicates changes in standards to appropriate department and division chiefs and provides follow-up to ensure new standards are being met; acts as a resource person for the medical staff, administration, and hospital staff; answers all questions regarding standards and the accreditation process; and researches questions and provides written documentation when applicable. Works collaboratively with the Accreditation Oversight Committee, Provision of Care Management Committee, Quality Management Groups and other resources in developing compliance strategies.

a. Remains current with Joint Commission standards and survey methodology. Ensures optimal compliance with accreditation and regulatory requirements of a variety of agencies. Analyzes compliance and accreditation standards, regulatory rules and hospital policies through evaluation of information. Communicates requirements/standards in a timely manner to MAMC leadership. Works collaboratively with departments and other resources in developing compliance strategies. Coordinates the overall hospital preparation for the Joint Commission survey. Remains current with all Joint Commission initiatives, ensuring that the hospital has an appropriate plan of action to ensure compliance. Serve as consultant on Joint Commission and hospital issues. Ensure that Joint Commission preparation, agendas, survey documents are prepared and correct and that all staff members are prepared, knowledgeable about the standards and key survey areas. Directs formulation of detailed plans/responses to accreditation and regulatory findings/inquiries.

b. Manages the MAMC’s Joint Commission continuous compliance program. Provides consultation to relevant action teams and committees to ensure ongoing compliance with standards. Collaborates with various disciplines, departments and services to assess compliance and develop compliance strategies. Translates standards, requirement and policies into terms or processes meaningful to the target area/department/facility. Assists all areas in the hospital in identifying areas of practice or performance which need improvement and assist in formulating plans for improvement.

c. Reviews, assesses, oversees and reports data from Joint Commission ORYX external database. Provides ongoing educational seminars, classes, and in-services to establish the Joint Commission preparation program, then monitors and evaluates overall progress of the program in accomplishing specific goals. Provides focused surveys, mock surveys, and unannounced surveys to assess state of readiness for surveys, focusing on continual preparation. Ensure that the Executive Committee is informed regarding the status of preparation for the Joint Commission survey and any operational deviations of a Joint Commission standard. The employee’s performance requires a high degree of analytical ability and a thorough understanding of pertinent basic statistical management and economic principles and techniques. The employee interprets and analyzes current legislation, directives and literature to include all Joint Commission standards and Inspector General Commentary and recommends proactive measures to maintain an optimal level of performance for all functions within available resources. Monitors compliance of ongoing programs designed to objectively and systematically monitor, evaluate and improve the quality and appropriateness of patient care provided for both inpatients and outpatients through surveys, audits and reports. The employee identifies areas of noncompliance and initiates corrective actions. The employee has wide latitude to exercise independent judgment in performing work of unusual difficulty and responsibility in this highly technical field.

3. Serves as the hospital's liaison to Joint Commission officials, Western Regional Medical Command (WRMC), and other regulatory agency administrators. Directs the ongoing preparation of the hospital for TJC surveys. In coordination with administration and department managers, plans and implements accreditation readiness program, survey agendas and documents, and meets with administration/department managers to ensure all staff members are prepared, knowledgeable about the standards and key survey areas. Prepares and directs staff members to assess compliance in their individual areas and to point out weak areas that require correction; and plans and coordinates Joint Commission mock surveys.

4. Responsible for planning and implementing a plan of correction/improvement for survey deficiencies; represents the hospital to Joint Commission when challenging/appealing any survey deficiencies; and maintains administrative control of records and documents related to Joint Commission standards and accreditation. Ensures all documentation is available to hospital staff. 

5. Directly supervises employees assigned (GS-7 Clerical Assistant). Plans and revises work schedules and assignments to assure an even flow and distribution of work, the expeditious handling of priorities, that schedules and deadlines are met and to meet changes in workload. Assigns responsibilities to subordinates, reviews the work and provides guidance and assistance on technical and administrative matters. Orients new subordinates, determines training needs and assures necessary on and off the job training needs are filled. Prepares requests for filling vacancies and selects subordinates. Prepares performance appraisals. Prepares requests and recommendations for promotion, reassignment, outstanding performance, etc. Approves and disapproves leave; charges employees AWOL; investigates and controls abnormal use of sick leave. Holds corrective interviews with subordinates, recommends disciplinary actions as deemed necessary; provides input to CPAC for official letters of reprimand; initiates suspension/removal actions; disapproves periodic step increases. Receives employee complaints and formal grievances, resolving those that can be resolved at the first supervisory level. Prepares workload and production reports as necessary and other reports as required. Reviews and interprets regulatory criteria and changes thereto. Keeps employees informed of management goals and objectives and higher level supervisors informed of employee concerns. Reviews and signs job descriptions, participates in position management and classification surveys. Participates in review and improvement of work methods, organizational features and the structuring of positions to eliminate unnecessary ones and achieve optimum content in those remaining. Implements specific and general provisions of government–wide and installation personnel, EEO and other programs; obtains technical information from responsible subject matter specialists. Indirectly supervises tracer team volunteers – between 10 and 30 individuals – orienting, training and supervising output of their work.

6. Serves as a member or consultant of several committees, including the Accreditation Oversight Committee, Patient Safety Committee, Nursing Documentation Committee, Inpatient Services Quality Management Group, Specialty Care Quality Management Group, Nursing Executive Committee, Provision of Care Management Committee and other Hospital Committees. These committees are comprised of department and service chiefs and other staff members, provides guidance, oversight and continuity of operations of the clinical staff and administrative functions. All committees receive and act on reports of other committees and other assigned activities. Also, propose new policies, procedures and regulations, when necessary to resolve process issues. 

Performs other duties as assigned.

US Citizenship required

At least one year of licensed clinical experience AFTER licensure as a registered nurse at the time of application