Management and Program Analyst

Duties

• Develop processes to assess and validate compliance checklists applicable to The Joint Commission standards.
• Analyze and provide accreditation compliance reports, executive summaries, and briefings to the executive staff.
• Develop and implement the execution of facility-wide mock surveys and analyze the results to identify and mandate correction of vulnerabilities.
• Manage the organization's preparation and report of significant findings related to patient care practices to the Quality Council, Medical Executive Committee (MSEC) and Executive Committee.
• Provide critical support to the Chief Medical Officer to ensure the organization is operated in strict compliance with the Defense Health Agency regulations.
• Ensure data is relevant and meets regulatory requirements for The Joint Commission and DoD compliance with Quality Improvement/Process Improvement program(s).
• Advise department chiefs and other staff on findings of analysis and recommends methods for improving outcomes.
• Serve as the Military Treatment Facility's senior technical expert for the Performance Improvement (PI) program.
• Develop policies and governance to standardize Performance Improvement (PI) procedures and training across the command.
• Facilitate performance improvement activities throughout the organization that includes the planning, developing, directing, organizing and evaluating of improvement initiatives and ongoing measures of organization performance.
• Collaborate with Patient Safety Manager, Risk Manager, Safety Manager, Clinical Operations, Patient Experience/Satisfaction, and Department Chiefs through the strategic planning process to prioritize quality assessment and performance improvement.

Requirements

Conditions of employment

• Appointment may be subject to a suitability or fitness determination, as determined by a completed background investigation.
• This position requires the incumbent be able to obtain and maintain a determination of eligibility for a Secret security clearance or access for the duration of employment. A background investigation and credit check are required.
• One year trial/probationary period may be required.
• This position has mandatory seasonal Influenza vaccination requirements and is subject to annual seasonal Influenza vaccinations unless otherwise exempted for medical or religious reasons (documentation of exemption must be provided upon hire).
• Immunization screening is required. Hepatitis B immunization is required for all positions with direct patient contact. Applicants may be required to show proof of other immunizations depending on the type of position.
• This position requires the incumbent to have Tuberculosis testing.
• Travel to up to 15% may be required to Naval Branch Health Clinics Indian Head, Dahlgren and Joint Base Andrews.

Qualifications

Who May Apply: US Citizens

In order to qualify, you must meet the experience requirements described below. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; student; social). You will receive credit for all qualifying experience, including volunteer experience. Your resume must clearly describe your relevant experience; if qualifying based on education, your transcripts will be required as part of your application. Additional information about transcripts is .

SPECIALIZED EXPERIENCE: One year of specialized experience which includes retrieving and analyzing healthcare data from electronic health systems to identify trends; interpreting and applying regulatory guidance to ensure compliance; supporting hospital readiness programs and standards for accreditation with The Joint Commission; and collaborating with hospital leadership/staff to identify deficiencies & recommend process improvements This definition of specialized experience is typical of work performed at the next lower grade/level position in the federal service (GS-11).

Some federal jobs allow you to substitute your education for the required experience in order to qualify. For this job, you must meet the qualification requirement using experience alone--no substitution of education for experience is permitted.

Additional information

• Male applicants born after December 31, 1959 must complete a Pre-Employment Certification Statement for Selective Service Registration.
• You will be required to provide proof of U.S. Citizenship.
• This position requires a 1 year probationary period during which the agency evaluates your fitness and whether your continued employment advances the public interest. In making this determination, the agency may consider your performance and conduct; agency needs and interests; whether your continued employment supports organizational or Government goals; and whether it promotes the efficiency of the Federal service. Continued employment requires written certification that it advances the public interest.
• Direct Deposit of Pay is required.
• Selection is subject to restrictions resulting from Department of Defense referral system for displaced employees.
• Recruitment or relocation incentives MAY be authorized for highly qualified candidates.
• Multiple positions may be filled from this announcement.
• Salary includes applicable locality pay or Local Market Supplement.
• When you perform a Civilian Permanent Change of Station (PCS) with the government, the Internal Revenue Service (IRS) considers the majority of your entitlements to be taxable. Visit for more information.
• If you have retired from federal service and you are interested in employment as a reemployed annuitant, see the information in the information sheet.
• Payment of Permanent Change of Station (PCS) costs is not authorized, based on a determination that a PCS move is not in the Government interest.