Registered Nurse - Accreditation Specialist

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:
• 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
• 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.

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The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.

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