The Accreditation and Quality (A&Q) Nurse Specialist demonstrates leadership in providing continuous readiness for accreditation and regulatory agency review and compliance (Joint Commission, Inspector General, Long Term Care Institute, CARF, etc.); performance and quality measures; organizational policy review; and program monitors and actions at Edward Hines Jr., VA Medical Center.

Duties

VISN 12 is committed to fostering and sustaining an environment which celebrates diversity, provides equitable opportunities for employment and promotion, and supports inclusiveness in our culture. Together, we strive to create and maintain working and learning environments that promote professional growth and teamwork, and are inclusive, equitable and welcoming. We embrace our differences as individuals and unite as a team toward a common goal: to serve our nation's Veterans. The Accreditation and Quality (A&Q) Nurse Specialist demonstrates leadership in providing continuous readiness for accreditation and regulatory agency review and compliance (Joint Commission, Inspector General, Long Term Care Institute, CARF, etc.); performance and quality measures; organizational policy review; and program monitors and actions at Edward Hines Jr., VA Medical Center. The A&Q Nurse Specialist reports directly to the Chief of Quality and Patient Safety. He/she is accountable for adhering to established policies, standards of care and standards of practice; demonstrating leadership in improving health care quality; and the administration, management, supervision and evaluation of both nursing and administrative personnel on his/her designated unit and as assigned for the Medical Center on the off tours, weekends, and holidays. Demonstrates, promotes, creates and ensures a culturally diverse workforce in which the values and needs of all individuals are respected. Provides an environment that fosters employees to perform to their full individual potential, while promoting psychological safety. The incumbent serves as a Specialist within the Accreditation & Quality Management Programs. - Serves as the point of contact and primary support (logistics such as arranging workspace and meals and coordinating staff for interviews) for site visitors engaged in the accreditation process. - Manages processes related to survey readiness, IPEC monitors, SAIL data, EPRP data, tracers, chart reviews, and environment of care surveillance. - Compiles regulatory data and communicates information to the Chief of Quality in a format that is conducive for utilization in decision making, strategic planning and performance improvement. - Chairs monthly meetings in support of deploying a systematic approach to readiness and integrating readiness activities in all areas. - Rounds frequently with staff to work with frontline staff at the unit-level on accreditation readiness issues. The incumbent works with team members of the Quality and Patient Safety Incumbent tracks, analyzes, and trends regulatory action plans and monitors for sustainment of improvement. May participate in root cause analysis, peer review, Lean Six Sigma teams, EPRP monitors, and employee surveys. Works in collaboration with the Patient Safety, HRO, Innovation, Systems Redesign, Risk Management, Infection Control and Utilization Management teams for tracers, chart reviews and QI initiatives. Troubleshoots issues related to quality of care and provides real time feedback to leadership. Responds on site in real time as incidents occur to investigate and prepare follow-up reports during administrative hours; follows-up next administrative day on occurrences during non-administrative tours. Edward Hines, Jr. VA Hospital is a Level 1a major interdisciplinary teaching facility with service-lines serving medical, surgical, and neurological inpatients and outpatients, with a comprehensive adult Emergency Department, and multiple community-based outpatient clinics (CBOC). There is a large outpatient psychiatric population, with admissions for medical co-morbidities. The Hines VA Hospital Blind Rehabilitation Center provides services in a residential setting. Home-Based Primary Care is provided in the veteran's home. 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, Tour hours between 6:00am - 6:30pm. ( 8 hours a day Mon - Fri). Telework: Not Available 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: MSN in Nursing or BSN with Masters in related field. 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 and objects may be required. Mechanical inpatient lifts are provided. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations, operative/invasive procedures, or home settings. 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. Must complete annual Employee Health requirements, such as annual 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 Edward Hines Junior Hospital 5000 South 5th Avenue Hines, IL 60141 US
• Name: Irene Balas
• Phone: 708-640-4736
• Email: [email protected]