at Veterans Affairs, Veterans Health Administration in Hines, Illinois, United States
Job Description
Summary The Accreditation and Quality (A&Q) Nurse Specialist demonstrates leadership in providing continuous readiness for accreditation and regulatory agency review and compliance (Joint Commission, Inspector General, Long Term Care Institute, CARF, etc.); performance and quality measures; organizational policy review; and program monitors and actions at Edward Hines Jr., VA Medical Center. Responsibilities VA offers a comprehensive total rewards package: VA Nurse Total Rewards The A&Q Nurse Specialist reports directly Chief of Quality. He/she is accountable for adhering to established policies, standards of care and standards of practice, demonstrating leadership in improving health care quality throughout the facility. Demonstrates, promotes, creates and ensures a culturally diverse workforce in which the values and needs of all individuals are respected. Provides an environment that fosters employees to perform to their full individual potential, while promoting psychological safety. Effectively, the A&Q Nurse Specialist serves as the point of contact and primary support (logistics such as arranging workspace and meals and coordinating staff for interviews) for site visitors engaged in the accreditation process. Manages processes related to survey readiness, IPEC monitors, SAIL data, EPRP data, tracers, chart reviews, and environment of care surveillance. Compiles regulatory data and communicates information to managers and senior leadership in a format that is conducive for utilization in decision making, strategic planning and performance improvement. Chairs or participates in monthly meetings in support of deploying a systematic approach to readiness and integrating readiness activities in all areas. Rounds frequently with staff to work with frontline staff at the unit-level on accreditation readiness and quality management issues. The incumbent works with team members of the Quality and Systems Improvement Department. Incumbent tracks, analyzes, and trends regulatory action plans and monitors for sustainment of improvement. May participate in root cause analysis, peer review, Lean Six Sigma teams, EPRP monitors, and employee surveys. Works in collaboration with the Patient Safety, HRO, Innovation, Systems Redesign, Risk Management, Infection Control and Utilization Management teams for tracers, chart reviews and QI initiatives. The incumbent serves as a Specialist within the Accreditation & Quality Management Programs. Serves as the point of contact and primary support (logistics such as arranging workspace and meals and coordinating staff for interviews) for site visitors engaged in the accreditation process. Manages processes related to survey readiness, IPEC monitors, SAIL data, EPRP data, tracers, chart reviews, and environment of care surveillance. Compiles regulatory data and communicates information to the Chief of Quality in a format that is conducive for utilization in decision making, strategic planning and performance improvement. Chairs monthly meetings in support of deploying a systematic approach to readiness and integrating readiness activities in all areas. Rounds frequently with staff to work with frontline staff at the unit-level on accreditation readiness issues. Troubleshoots issues related to quality of care and provides real time feedback to leadership. Responds on site in real time as incidents occur to investigate and prepare follow-up reports during administrative hours; follows-up next administrative day on occurrences during non-administrative tours. Duties of this position directly affect the internal security of the agency. Internal security includes investigations/audits of patient care records for several purposes such as fact finding, sentinel events, surveillance, performance improvement, root cause analyses, FMEA, and regulatory agency requests (i.e., OIG, TJC, etc.) which are imperative to the functional operation of the organization in carrying out its mission to improve health care for our veterans. 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: Monday – Friday, 8-hour tours (7:00am – 5:30pm) Compressed/Flexible: Not Available Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Requirements Conditions of Employment U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) – See “Additional Information” below for details. Qualifications 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 nur
