The Accreditation Manager (AM) Registered Nurse is assigned to the Quality Management Service, Office of the Director. The Accreditation Manager (AM) is a registered professional nurse, qualified by education and experience to monitor and evaluate clinical and administrative processes for the delivery of patient care for the Jonathan M. Wainwright Memorial VA Medical Center and Community-Based Outpatient Clinics.

Duties

The incumbent leads all readiness activities for accreditation by The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and various other internal and external audits/reviews. Duties include but are not limited to: Develops, implements, evaluates, sustains, and reports on accreditation-related programs, processes, and activities to maintain VAWW continual readiness and safe, high quality patient care. Competently assumes the leadership roles and responsibilities needed to guide VAWW continual survey readiness and related quality improvement activities. Applies leadership, communication, team building skills and the principles of adult education to improve staff knowledge and attitudes about compliance with VA/VHA and guidance and accreditation standards. Serves as accreditation subject matter expert for staff at all organizational levels to support strategic decision-making, organizational initiatives, and performance improvement interventions. Maintains documentation and data as required for continual readiness. Completes survey-related administrative processes. Provides consultation and support to all levels of facility leadership and others responsible for VAWW accreditation activities, including all accreditation related requirements, policy initiation/revision, readiness preparation, intra-survey facilitation, and development, implementation, and monitoring of post-survey corrective action plans. Plans, facilitates, conducts, and documents clinical tracers, walkabouts, and quality monitoring audits, as scheduled and as needed, focusing on continual survey readiness and evaluation of specific corrective action plans. Reports findings to process owners and tracks corrective action plans. Evaluates patient medical records for compliance with outpatient services policies and accreditation requirements. Interviews staff and patients and observes care to assess and improve compliance with regulations and guidance. Initiates, conducts, evaluates, and documents risk assessments, reporting findings and recommendations to organization leaders. Participates on VAWW committees as an accreditation and quality content expert. Educates staff about accreditation related regulations and standards, VA/VHA and VISN 20 guidance, and VA Office of Inspector General (VAOIG) focus initiatives. Provides consultation to ensure that Medical Center Memoranda correctly and complete address all accreditation-related requirements. Evaluates accreditation and quality monitoring data and recommends improvement actions through informative reporting as required, to facility committees, boards, councils, and senior leaders. Demonstrates leadership that is sustainable regardless of role and incorporates professional standards of care and implements broad-reaching evidence-based change. 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, 8:00 am - 4:30 pm Telework: May be authorized at Supervisory discretion. Virtual: This is not a virtual position Relocation/Recruitment Incentives: Authorized. Financial Disclosure Report: Not required

Requirements

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), 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 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). 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. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12321610. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Preferred Experience: VA experience Accreditation experience 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: Moderate lifting (15-44 pounds), Moderate carrying (15-44 pounds), Straight pulling (.5 hours), Pushing (.5 hours), Reaching above shoulder, Both hands required, Use of fingers, Walking (2.5 hours), Standing (5 hours), Repeated bending, Operation of crane, truck, tractor or motor vehicle, Ability to distinguish basic colors, Hearing (aid permitted).

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Jonathan M Wainwright Memorial VA Medical Center 77 Wainwright Drive Walla Walla, WA 99362 US
• Name: Laura Wallace
• Phone: 5414401000 X40529
• Email: [email protected]