This position is in Quality Management Service. The incumbent assists in the medical center's activities and preparations for the Joint Commission, Inspector General, and other external reviews. The incumbent works closely with the Systems Redesign Coordinator, Risk Manager, Patient Safety Manager, Medical Center Leadership, service chiefs and section chiefs, middle managers, and front-line staff.

Duties

The Accreditation Nurse: 1. Plans and manages the healthcare system's accreditation and review programs, to include but not limited to, TJC surveys (Hospital, Home Care, Behavioral Health, and Lab), OIG CHIP survey, and Commission on Accreditation of Rehabilitation Facilities (CARF) survey. Coordinates and conducts the ongoing TJC annual periodic performance. Coordinates and conducts routine tracers and inspections to identify areas of concerns or opportunities for improvements. 2. Ensures TJC application is kept current and meets deadlines as required. 3. Serves as the subject matter expert on TJC and other external accrediting agencies for staff to request information or get questions answered. 4. Responsible for program development and management of a continuous readiness program and providing clinical and administrative guidance relative to all quality improvement and external accreditation standards within the healthcare system. 5. Ensures all components of TJC Periodic Performance Review (PPR) are reviewed and entered in TJC PPR to monitor continuous readiness. The PPR is a dynamic document and will be updated on an ongoing basis with submissions to TJC on an annual basis. 6. Tracks all action plans identified in the PPR to resolution. 7. Utilizes data from the database to prepare reports and graphical presentations of data related to continuous readiness for senior leadership, service chiefs, and committees as appropriate. 8. Promotes and facilitates ongoing effective communication throughout the facility respective to all external accreditation standards and quality improvement activities. 9. Utilizes VHA HRO principles and educates staff on the HRO principles to foster a robust culture of safety and process improvement. 10. Demonstrates dedication to the nursing profession and represents nursing in the community and professional activities. 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, 7:30am-4:00pm Telework: Ad-Hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required Pay Schedule: NF45

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: Master's in Nursing preferred 5-8 years Nursing experience 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: It is VA policy to ensure that all selected applicants and employed personnel are physically, mentally and emotionally fit to perform the duties of the position to which assigned. A pre-placement physical examination is required for all fulltime, part-time and intermittent employees identified by VA Directive and Handbook 5019. The pre-placement physical examination shall be completed prior to appointment to determine the physical and mental fitness for candidates for appointment in VA. The examination will be concerned with the mental and physical ability of the applicant to satisfactorily perform the duties of the proposed assignment and will include requisite laboratory and other screening as required by Federal regulatory agencies. 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. This position requires that you are able to lift at least 50 lbs. Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. 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 organizational needs. Must complete annual Employee Health requirements, such as annual Influenza vaccination, TB screening or testing, as a condition of employment.

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 Robley Rex VA Medical Center 800 Zorn Avenue Louisville, KY 40206 US
• Name: Sean Shepherd
• Phone: 615-695-2251
• Email: [email protected]