The Accreditation/PI Consultant is responsible to the Deputy Chief, Quality and Patient Safety Service, who is directly responsible to the Chief of Quality and Patient Safety Service. The incumbent is responsible for consulting and providing leadership in the area of performance improvement, including facilitation of performance improvement projects, collecting, and analyzing data and assist with ongoing monitoring of metrics.

Duties

The incumbent is responsible for consulting and providing leadership in the area of performance improvement, including facilitation of performance improvement projects, collecting, and analyzing data and assist with ongoing monitoring of metrics. The incumbent must be familiar with Performance improvement standards, assess areas of responsibility for fulfillment of those standards, and maintain ongoing emphasis on achieving High Reliability. The incumbent must be an educator, keeping staff up to date on changes within the standards and assuring their fulfillment of new concepts that are mandated by the external review entity. The incumbent is responsible for maintaining a continuous survey readiness program that includes but is not limited to mock tracer rounds review and follow-up. The incumbent must collaborate with other Accreditation/PI Consultants on the implementation of new standards in addition they must work with the appropriate point of contact to assure that adequate PI Data knowledge is prevalent by staff. The incumbent must be familiar with the VHA Directives that relate to their area of performance improvement. The incumbent is primarily responsible for the Hospital Accreditation Program Manual which includes all hospital based ambulatory care specialty services. However, responsibilities and schedules are subject to change based on staffing and need. The incumbent will be responsible for preparing staff for Joint Commission, attending and communication vital information through committees and meetings, and preparing for other audits such as the Office of Inspector General. Full familiarity of The Joint Commission website must be maintained. The incumbent must be familiar with the VHA Directives that relate to their area of performance improvement relate to their area of performance improvement. The incumbent may be given other duties that are not listed above but are assessing, providing intervention, measurement of success and oversight of whether improvement has been sustained. The PI/Accreditation Nurse must be flexible at all times, assuming new responsibilities based on prioritization set forth by Executive Leadership. Teaches PSTT (Patient Safety Teams Training) to all nursing staff and providers. (First in our VISN to implement PSTT Training) PSTT is a National Training Program that empowers all members of the clinical team to work together more effectively for patient safety and improve outcomes. It provides tools and resources to feel empowered to "Speak Up" for patient safety. The Performance Improvement Accreditation Consultant will be responsible for providing leadership in the aspects of assessment, measurement, and process improvement regarding patient/resident care and organizational functions. The incumbent will develop and coordinate facility-wide accreditation and Performance Improvement Plans. Demonstrating knowledge and the ability to apply principles of evidence-based practice. The Performance Improvement Accreditation Consultant will provide support at the unit, service, and organizational levels. Key responsibilities for the incumbent will be tracking, analyzing, and trending process activities in patient/resident care and organizational functions for continued survey readiness. The incumbent has the responsibilities as a Performance Improvement Accreditation Consultant for the development, implementation, and maintenance of the Quality and Patient Safety programs that include the delineation of standards and parameters of quality improvement in all aspects of patient care. The incumbent will be accountable for the measurement and health outcomes for the continuous survey readiness program and implementation in continuous quality improvement, personal development and team building for The Joint Commission Standards.

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 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). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Preferred Experience: At least 3-5 years experience in a acute care setting Knowledge of data collection Knowledge of other internal regulatory review processes(OIG, TJC) Current concepts of quality improvement Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: Heavy lifting (45 lbs. and over); or Moderate Carrying (15-44 pounds); or Straight Pulling; Pushing; Reaching above Shoulder; Walking; Standing; Repeated bending; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Hearing aid (permitted); Ability to distinguish basic colors; Ability to distinguish shades of colors; Depth perception; Both eyes required; Both legs required; Use of fingers and both hands required.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Jerry L Pettis Memorial Veterans Hospital 11201 Benton Street Loma Linda, CA 92357 US
• Name: Michele Howard
• Phone: 909-871-7413
• Email: [email protected]