The Accreditation Specialists is recognized as one of two facility's point of contact working collaboratively with various medical center employees and leaders to build a culture of continuous readiness with guidance for the implementation of sustaining actions, or processes to meet external and internal standards, policies, and directives.

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. The Accreditation Specialist has independent responsibilities include but not limited to 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 have 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. 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: Monday through Friday, 7:30 a.m. - 4:00 p.m. Subject to change based on agency needs. Telework: At the supervisor' discretion, Ad-hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: May be Authorized Permanent Change of Station (PCS): Not 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/12362827. 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. 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: The physical requirements of this position include lifting, prolonged standing and sitting, frequent bending, walking (distance), climbing, reaching (overhead, extensive/repetitive), pulling, pushing, repetitive motion and stooping. The mental/sensory requirements include recall, reasoning, problem-solving, hearing, speaking clearly, writing legibly, keyboarding, reading and logical thinking, depth perception, hearing (aide permitted); near/far vision correctable to meet Driver's License requirements. The environment's pace can vary from steady to a sometimes-fast pace requiring handling of multiple priorities, frequent, sometimes intense customer interactions, and the ability to adapt to frequent changes in a sometimes-noisy environment. There may be the need to use personal protective equipment to prevent exposure to disease, illness and hazardous materials.

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: Linda Parker
• Email: [email protected]