The Quality Consultant will be responsible for the ongoing development and maintenance of a continuous readiness program which ensures facility accreditation and compliance with external accrediting standards and internal performance expectations as delineated in VHA guidelines / directives. The incumbent will promote a culture of continuous readiness within an enterprise risk management framework, driving improvement and developing processes which support safe and efficient patient care.

Duties

Major duties include, but may not be limited to: - Clinical: Uses clinical knowledge to evaluate the quality and effectiveness of clinical performance within the facility, using data collected by internal and external monitoring processes. Relays this information to clinical leadership and senior leaders. - Uses clinical knowledge to provide day-to-day evaluation of situations which might not meet accreditation and VHA standards, implementing strategies to develop performance improvement plans. Promotes sustainability of said plans. - Uses clinical knowledge to complete individual quality reviews and/or case assessments to determine which improvement efforts are necessary to improve care delivery. Implements relevant improvement strategies, which may include, but are not limited to, one-on-one teaching, group educational sessions, and process redesign, and /or review. - Possesses a thorough working knowledge of the directives, policies, and performance standards of the Veterans Health Administration (VHA) arm of the Department of Veterans Affairs. - Possesses a thorough working knowledge of The Joint Commission and other oversight agency standards, such as the Commission on Accreditation of Rehabilitation Facilities (CARF), Long Term Care Institute (LTCI), the Office of the VA Inspector General and its Combined Assessment Program (OIG-CAP), and a host of other accrediting agencies as they relate to the enterprise risk-management framework. - Utilizes knowledge of medical terminology, anatomy, physiology, medical and nursing diagnoses, reading, and interpreting orders, lab values, progress notes, medications, and treatment plans, to be able to determine and discuss the appropriateness of health care provided by various health care professionals at VANCHCS. - Responsible for translating theories, strategies, and national policies into action within the complex interrelationships that exist related to continuous readiness. - Leads, directs, and assists healthcare system staff in the preparation and successful completion of external accreditation surveys. - Sits on various health care system committees as mandated by VHA and/or local policy. Chairs committees or ad hoc groups aimed at accreditation preparation, continuous readiness, and/or meeting facility performance standards. - Works with staff throughout the healthcare system to develop corrective action plans which address deficiencies in practice and opportunities for improvement. - Serves as accreditation liaison with The Joint Commission, Office of Inspector General (OIG), Long Term Care Institute (LTCI), the Commission on Accreditation of Rehabilitation Facilities (CARF), and a host of other accrediting agencies as assigned. - Completes other assignments as delegated by the Chief of Quality Management and/or Director of Accreditation, Risk Management, and Patient Safety or the Medical Center Director. 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: 0800-1630 Telework: Available - as determined by the agency policy 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. 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. 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: Includes, but not limited to: - Involves considerable amount of standing, walking, stooping, bending, reaching, lifting, and turning. - Requires carrying or lifting of objects weighing up to 50lbs; may require going up and down flights of stairs. - Requires ability to drive an automobile to sites throughout NCHCS. - The work involves moderate risk of exposure to contagious/infectious disease, radiation, or working with emotionally disturbed patients. - Requires use of hands for actions such as typing, grasping, fine manipulation, and repetitive actions. - Requires the ability to frequently respond to multiple demands and priorities. - Emotional and mental stability - ability to effectively perform the essential functions of the position and respond appropriately in emergency situations.

Education

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 VA Northern California Health Care System 10535 Hospital Way Mather, CA 95655 US
• Name: Calvin Samonte
• Phone: 415-221-4810
• Email: [email protected]