The incumbent functions in Quality Management as of one of two Accreditation Specialists for the Medical Center and surrounding Clinic Based Outpatient Clinics. The Accreditation Specialist will collaborate with the interdisciplinary team, and creates a positive work environment which enhances the interdisciplinary delivery of care based on patient needs.

Duties

The Accreditation Specialist leads, directs, and assists medical center leadership in interpreting external standards and directives to enhance continuous readiness throughout the organization. H/She provides clinical and administrative recommendations relative to the implementation of program initiatives and related application of quality management, accreditation, and other external standards within the medical center. The incumbent also coordinates the medical center's Focused Standards Assessment for the Joint Commission, coordinates post-survey requirements such as Evidence of Standards Compliance and Measures of Success, oversees an external review data base and monitors actions related to recommendations from external review bodies including the Joint Commission, CAP, OIG, OMI, etc. H/She contributes to departmental and/or facility policy development, planning, and evaluation which affect the delivery and quality of care provided and is a non-bargaining employee. The Accreditation Specialist has independent responsibility for the following: Provides consultation/collaboration and guidance in accreditation standards and quality management (QM), principles, systems, and processes for the improvement of patient care. Assists hospital staff to identify accreditation QM issues and promote systematic processes for problem analysis and resolution. Initiates/coordinates interdisciplinary projects/teams to improve patient care delivery and organizational systems. Plans and directs timely follow-up of review findings. 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. Demonstrates effective communication skills. and interpersonal relationships in working with both committees and individuals. Collaborates with medical center leadership in making decisions and developing/implementing action plans throughout the medical center. Interprets rules and regulations and has a broad knowledge of VHA regulations, Joint Commission, and other applicable Federal and State requirements in order to provide accurate information for management and clinicians regarding accreditation standards and quality management-related issues. Chairs or serves as a member of committees and task forces related to performance improvement functions. Provides leadership and expertise to committees, task forces, as well as project assignments, developing data, forming plans, and preparing position papers that impact on planning for quality and performance management as a whole. Serves as a liaison to the Joint Commission 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 and the appropriateness and timeliness of services provided. Demonstrates the knowledge and skills necessary to manage the program requirements including sound managerial skills to establish priorities and accomplish the tasks. Functions as a consultant/resource in center-wide committees and activities that relate to program issues. Can use the computer i.e., Excel, Word, PowerPoint, and CPRSNISTA in performing job requirements. Other duties as assigned. 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: 7:30a-4:00pm Monday-Friday (tour of duty subject to change based on agency needs) Telework: Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: 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 the appropriate State-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). 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. 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: 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. Transferring patients from stretcher to stretcher and wheelchair to exam table is often 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 patient needs.

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 Ralph H Johnson Department of Veterans Affairs Medical Center 109 Bee Street Charleston, SC 29401 US
• Name: James Ledlow
• Email: [email protected]