at Veterans Affairs, Veterans Health Administration in Danville, Illinois, United States
Job Description
Summary The Registered Nurse (RN) Accreditation/Continue Survey Readiness Specialist provides clinical and administrative recommendations relative to the implementation of program initiatives, accreditation, and other external standards within the medical center. The incumbent coordinates the accreditation applications, coordinates pre, intra and post-survey activities including Evidence of Standards Compliance, facilitate and monitor closure of all survey/inspection recommendation. Responsibilities The RN, Accreditation/Continue Survey Readiness Specialist, Quality & Patient Safety, has duties that include but are not limited to the following: Responsible for the management of accreditation and survey readiness activities for the facility and Community Based Outpatient Clinics (CBOC) which encompasses planning, organizing, directing, and overseeing accreditation and other external surveys and site visits such as: TJC, HFI, OIG, OMI, CARF, CLC surveys, etc. Provides consultation, collaboration, facilitation and guidance in accreditation standards, directives, processes improvement and continue survey readiness, plans and directs timely follow up of review findings. Assists hospital staff to identify accreditation issues and promote continue process improvement (CPI). Initiates/coordinates interdisciplinary projects/teams to improve patient care delivery and organizational systems. Shares expertise with hospital employees using a variety of educational, collaborative, and collegial formats. Collects and analyzes data and develops reports to appropriately disseminate programmatic findings and recommendations. Demonstrate effective communication skills and interpersonal relationships in working with both committees and individuals, and collaborate with facility leadership in planning and decisions making and implementing action plans when needed. Serves as a liaison with TJC, HFI, OIG, OMI, CARF, CLC surveys, and other external review groups and provides direct staff support to service chiefs, and others in planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of program components and or services to improve the quality of patient care, appropriateness and timeliness of services provided. Complete TJC complaints and extra views including OIG hotlines and non-case referrals. Duties require the ability to apply specialized principles and practices to ensure a systems approach to healthcare delivery. 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: Monday – Friday, 7:30 am – 4:00 pm Telework: Available, Ad Hoc Virtual: This is not a virtual position. 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 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. Preferred Experience: Two (2) years of Quality Management experience, five (5) years clinical Nursing experience; BSN preferred. 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/12475392. 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 Bache