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

VA offers a comprehensive total rewards package: VA Nurse Total Rewards The A&Q Nurse Specialist reports directly Deputy Chief Nurse of Quality & Patient Safety. He/she is accountable for adhering to established policies, standards of care and standards of practice He/she is accountable for adhering to established policies, standards of care and standards of practice, demonstrating leadership in improving health care quality throughout the facility. 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. Effectively, the A&Q Nurse Specialist 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 managers and senior leadership in a format that is conducive for utilization in decision making, strategic planning and performance improvement. Chairs or participates in 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 and quality management issues. The incumbent works with team members of the Quality and Systems Improvement Department. 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. 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. 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. Duties of this position directly affect the internal security of the agency. Internal security includes investigations/audits of patient care records for several purposes such as fact finding, sentinel events, surveillance, performance improvement, root cause analyses, FMEA, and regulatory agency requests (i.e., OIG, TJC, etc.) which are imperative to the functional operation of the organization in carrying out its mission to improve health care for our veterans. 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-hour tours (7:00am - 5:30pm) Compressed/Flexible: Not Available 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

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/12517319. 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: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Preferred Experience: Prefer 3+ years of accreditation experience (TJC, CARF, Ascellon, etc.) Home Care experience a plus. Master of Science Degree in Nursing (MSN). 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. The incumbent who provides care in home settings or other off-site locations may be required to drive and/or ride in GSA-vehicles.

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: Divya Gupta
• Phone: 2023949562
• Email: [email protected]