The Health Systems Specialist - Accreditation position is located at the Carl Vinson VA Medical Center in Dublin, GA within the Quality, Safety and Value (QSV) service line, and has responsibilities that span all locations including but not limited to the Dublin campus and all seven surrounding community-based outpatient clinics (CBOCs).

Duties

The Accreditation Specialist has continuous responsibility to track and verify the changes in the accreditation processes with respect to all clinical processes at the Carl Vinson VA Medical Center including The Joint Commission (TJC); OIG, CARF, and LTCI. The incumbent must keep abreast of all relevant accreditation publications, notices, and updated directives to ensure the Quality and Safety and Value (QSV) Office, leadership and other stakeholders can react competently to current events to enhance senior management ability to facilitate accurate communication and transparency. Major duties include but are not limited to: Accreditation Oversight/Management: serves as the Medical Center's Subject Matter Expert (SME) and primary authority on accreditation standards and practices; serves as consultant and advisor to the Chief of QSV and appropriate management officials to include performing as the facility continuous survey readiness point of contact; provides assistance and advice concerning the development and improvement of departmental and /or services PI plans throughout the Medical Center; Analyzes and provides recommendations for improving efficiency and quality for Departments, Committees, or Process Improvement Teams (PITS) through standardization or introduction of new methodologies that correlate and interrupt the current accreditation standards and all other requirements; Ensures optimal compliance with accreditation and regulatory requirements across a variety of Federal agencies; Analyzes compliance and accreditation standards, regulatory rules and hospital policies through evaluation of system information to ensure optimal compliance with survey regulations. Program Planning: Works collaboratively with key stakeholders in the development of programmatic goalsin the QSV; Establishes and maintains inclusive partnerships and feedback systems across the Medical Center which promote ongoing improvement; Demonstrates the skills and abilities to develop and apply comprehensive strategies for evaluating and improving quality, safety, and efficiency outcomes; Maintains an awareness of advancements in technologies for new techniques in the field; Supports planning efforts in implementing new logistical arrangements aimed at improving clinical services; Plays a critical support role in the planning and development of actionable focused outcomes to promote accountability within the clinical and administrative services to develop efficient and sustainable processes; Supports the QSV service in the establishing and the maintenance of the Carl Vinson Medical Center as a LEAN Healthcare organization; Develops procedures and systems for establishing, operating, and assessing the effectiveness of clinical and administrative control systems and operating programs; and the accomplishment, evaluation, and/or monitoring of audits, inspections, or management or internal control reviews. Special Projects: Conducts special assignments as delegated by the Chief of QSV, in relation to performance improvement issues, the overall CVVAMC mission and/or items in the best interest of the Medical Center; Compiles information and data, summarizes findings, analyzes findings, develops recommendations, and present recommendations in final report form; Develops guidelines and new methods to address deficiencies, ensure compliance and implement improvements; Demonstrates solid knowledge of accreditation programs, and their interrelationships between health care delivery systems within the Medical Center. The preferred candidate will have Environment of Care and Life Safety accreditation knowledge; proficiency in Microsoft Excel with the creation of complex dashboards and tracking tools; and proficiency with engineering terminology demonstrated by knowledge of NFPA Life Safety Codes. Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. Work Schedule: Monday - Friday, 8:00AM - 4:30PM Telework: This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Position Description/PD#: Health System Specialist - Accreditation/PD105890 and PD111290 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not Required

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/03/2023. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet Time-In-Grade requirements by the closing date of this announcement. For a GS-12 grade position you must have served 52 weeks at the GS-11 grade. For a GS-11 grade position you must have served 52 weeks at the GS-9 grade. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your Time-In-Grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year Time-In-Grade, as required by this job announcement. In that instance, you must provide an additional SF-50 that clearly demonstrates the one-year Time-In-Grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. INDIVIDUAL OCCUPATIONAL REQUIREMENT (IOR): An IOR is a basic requirement that must be met in order to qualify for entry into this job series, and it is something that cannot be waived. To qualify for the 0671 occupational series, all applicants must meet one of the following: Undergraduate and Graduate Education: Major study in hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration. OR Specialized experience: Progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/ or coordination of administrative, clinical, or other service activities, and provided knowledge of the following: Missions, organizations, programs, and requirements of health care delivery systems; Regulations and standards of various regulatory and credentialing groups; and Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. OR Special Provision for In-service Placement: Successful completion of an agency-sponsored on-the-job training program may be substituted for qualifying experience, provided it included a formal individualized training plan. Such a training program must have been conducted in an operating health care system and included: Assignments providing a knowledge of basic health system administration philosophies, practices, and procedures, and basic government administrative policies and requirements; Practical assignments providing an opportunity to apply health system administration skills and principles (as the individual progresses, work assignments must be characteristic of the grade level to which he or she is assigned); and Oversight by an experienced health system administrator with periodic evaluation of the individual's progress and appropriate adjustment of the training program. GS-11 QUALIFICATION: To qualify for this position at the GS-11 grade you must meet one of the following: Specialized Experience:One (1) year of specialized experience equivalent to the next lower level GS-9. Examples of specialized experience for this position include but are not limited to: Assisting with analysis of the Medical Center's accreditation and compliance standards. Assisting with development of recommendations to address deficiencies by gathering data, summarizing and analyzing survey findings. Assisting with development of programmatic goals, standardizing and/or introducing new methodologies, and ensuring optimal compliance with survey regulations. OR Education:Ph.D. or equivalent doctoral degree; or three (3) full years of progressively higher-level graduate education leading to such a degree; or LL.M., if related. (TRANSCRIPTS REQUIRED) GS-12 QUALIFICATION: To qualify for this position at the GS-12 grade you must have one (1) year of specialized experience equivalent to the next lower level GS-11. Examples of specialized experience for this position include but are not limited to: Analyzing compliance and accreditation standards while serving as Subject Matter Expert on the Medical Center's accreditation standards and practices. Gathering data, summarizing and analyzing survey findings, developing recommendations to address deficiencies, ensuring compliance, implementing improvements, and presenting in report form to key stakeholders. Developing programmatic goals, standardizing and/or introducing new methodologies, and ensuring optimal compliance with survey regulations. In order to receive credit for any relevant specialized experience, it must be listed on your resume with job titles, detailed descriptions of duties, start/end dates, and GS-grades. Failure to follow this requirement may result in your qualifications being undetermined and your application being considered ineligible. You will be rated on the following Competencies for this position: Quality Management Data Management Communication Compliance Analysis and Problem Solving Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. Physical Requirements: No special physical demands are required. Carrying reports, medical records, and utilizing the computer terminal are required. Most of the work is performed while seated, although driving and walking are required due to the geographical size of the Medical Center. Incumbent may be required to travel to all major Medical Center sites as needed to include Dublin and the surrounding Community Based Outpatient Centers (CBOCs). For more information on these qualification standards, please visit the following OPM website.

Education

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

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 educational accreditation status here.

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 additional information, please review this link.

Contacts

• Address Carl Vinson VA Medical Center 1826 Veterans Boulevard Dublin, GA 31021 US
• Name: VHA National Recruitment Center
• Phone: (844)456-5208
• Email: [email protected]