Summary

The Accreditation Specialist is responsible for ensuring the facility meets all regulatory and accreditation standards. The role focuses on monitoring compliance - coordinating surveys - leading readiness efforts - analyzing performance data - driving continuous quality improvement initiatives - conducting tracer activities/mock surveys/gap analyses; partners with leadership to develop - implement - and monitor corrective action plans - and provides education to all staff on regulatory standards.

Qualifications

Preferred Experience: Regulatory knowledge and experience - survey readiness - performance improvement and clinical credibility. Minimum of 5 years of RN experience in mental health - long-term care - specialty care or ambulatory care. Minimum of 5 years experience in the following areas: Demonstrated knowledge of standards of nursing practice - documentation requirements - patient safety principles - performance improvement and infection prevention practices. Accreditation survey preparation - regulatory compliance monitoring - mock tracers and survey tracers - standards interpretation and gap analyses. Experience working with The Joint Commission. Experience developing - revising and managing clinical policies and standard operating procedures. Conducting internal tracers - preparing leadership and frontline staff for surveys - and writing corrective action plans. Experience providing leadership briefings

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (Reference VA Handbook 5005 - Appendix G6)
• OR In cases of graduates of foreign schools of professional nursing - possession of a current - full - active - and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12940257
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: The population of male and female veterans served ranges from the adult - age 18 - to the elderly adult - age 65 and over
• TVAMC services medical - geriatric and mental health inpatients - residents and outpatients
• This position requires visual acuity - keen hearing - clear distinctive speech - and manual dexterity
• This position requires potentially long periods of continued walking - standing - stooping - sitting - bending - pulling - and pushing
• Transferring patients and objects may be required
• The incumbent may be exposed to infected patients and contaminated materials and may be required to don personal protective equipment
• The incumbent may occasionally be exposed to patients who are combative secondary to delirium - dementia - or psychiatric disorders
• The incumbent must be a mature - flexible - sensible individual capable of working effectively in stressful situations - able to shift priorities based on patient needs.

Duties

• Demonstrates integration of biopsychosocial concepts - cognitive skills - and technically competent practice while providing care to clients
• Assesses - plans - implements - and evaluates delivery of care based on age specific components
• Demonstrates performance and leadership that is broad enough to improve the care for a group of patients
• Collaborates with members of the interdisciplinary team and leading to process improvement initiatives
• Assumes responsibility for the coordination of care focused on patient education - self-management - and customer satisfaction throughout the continuum of care
• Follows procedures per established policies and guidelines
• Duties include but not limited to: The Quality Management (QM) Consultant Registered Nurse (RN) demonstrates ability and creative approaches to improvement in quality-of-care outcomes
• The QM Consultant demonstrates performance that improves the care for a group of patients
• They are responsible for participation in the documented outcomes at the program level
• Program level outcomes must be demonstrated at any organizational level within a department and/or facility
• Program is defined as a substantial coordinated group of activities impacting patients and/or employees
• The QM Consultant is assigned responsibility for their assigned QM program area activities for the Medical Center and all off-site locations
• The QM Consultant collects data - monitors staff compliance with relevant policies - directives - and standards - provides reports detailing trends - and provides direct staff support to all services in planning - designing - integrating - implementing - modifying - and administering - a comprehensive quality management program area
• The QM Consultant participates in facility councils - committees - and workgroups
• VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary - regular salary increases - potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Full time Monday - Friday 7:30 am - 4:00 pm Telework: Not Available
• Virtual: This is not a virtual position
• Permanent Change of Station (PCS): Not authorized.