The Accreditation Manager (AM) Registered Nurse is assigned to the Quality Management Service, Office of the Director. The Accreditation Manager (AM) is a registered professional nurse, qualified by education and experience to monitor and evaluate clinical and administrative processes for the delivery of patient care for the Jonathan M. Wainwright Memorial VA Medical Center and Community-Based Outpatient Clinics.

Duties

The incumbent leads all readiness activities for accreditation by The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and various other internal and external audits/reviews. Duties include but are not limited to: Develops, implements, evaluates, sustains, and reports on accreditation-related programs, processes, and activities to maintain VAWW continual readiness and safe, high quality patient care. Competently assumes the leadership roles and responsibilities needed to guide VAWW continual survey readiness and related quality improvement activities. Applies leadership, communication, team building skills and the principles of adult education to improve staff knowledge and attitudes about compliance with VA/VHA and guidance and accreditation standards. Serves as accreditation subject matter expert for staff at all organizational levels to support strategic decision-making, organizational initiatives, and performance improvement interventions. Maintains documentation and data as required for continual readiness. Completes survey-related administrative processes. Provides consultation and support to all levels of facility leadership and others responsible for VAWW accreditation activities, including all accreditation related requirements, policy initiation/revision, readiness preparation, intra-survey facilitation, and development, implementation, and monitoring of post-survey corrective action plans. Plans, facilitates, conducts, and documents clinical tracers, walkabouts, and quality monitoring audits, as scheduled and as needed, focusing on continual survey readiness and evaluation of specific corrective action plans. Reports findings to process owners and tracks corrective action plans. Evaluates patient medical records for compliance with outpatient services policies and accreditation requirements. Interviews staff and patients and observes care to assess and improve compliance with regulations and guidance. Initiates, conducts, evaluates, and documents risk assessments, reporting findings and recommendations to organization leaders. Participates on VAWW committees as an accreditation and quality content expert. Educates staff about accreditation related regulations and standards, VA/VHA and VISN 20 guidance, and VA Office of Inspector General (VAOIG) focus initiatives. Provides consultation to ensure that Medical Center Memoranda correctly and complete address all accreditation-related requirements. Evaluates accreditation and quality monitoring data and recommends improvement actions through informative reporting as required, to facility committees, boards, councils, and senior leaders. Demonstrates leadership that is sustainable regardless of role and incorporates professional standards of care and implements broad-reaching evidence-based change. Serves as an high reliability steward and works to quickly identify anomalies, or problems in processes. Embody the 5 principles of high reliability: sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, and resilience. Identifies and implements risk controls and mitigation strategies Drafts and reviews risk management policies and protocols Reports on risk findings and make recommendations to the medical center director or other stakeholders 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, 8:00 am - 4:30 pm Telework: May be authorized at Supervisory discretion. 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

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: Prefer Accreditation Experience. Prefer previous VA experience. Prefer 3-5 years nursing experience BSN preferred 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. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. 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: Moderate lifting (15-44 lbs), Moderate Carrying (15-44 lbs), straight pulling (.5 hr), pushing (.5 hrs), reaching above shoulder, use of fingers, walking (3 hrs), standing (5 hrs), repeated bending , operation of crane, truck, tractor, or motor vehicle, ability to distinguish basic colors, ability to distinguish shades of color, hearing (aid permitted).

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 Jonathan M Wainwright Memorial VA Medical Center 77 Wainwright Drive Walla Walla, WA 99362 US
• Name: Stephenie Merrill
• Phone: 509-525-5200 X26794
• Email: [email protected]