Summary

The Registered Nurse {RN) who serves as the Accreditation Coordinator in the Quality Management Service. He/she is designated a technical advisor in all matters pertaining to accreditation and continuous readiness and coordinates all accreditation activities with affected individuals/services {e.g. - presurvey/post survey requirements - associated Issue Briefs - Action Items).

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/13105630
• 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: Experience with preparation - coordination - and knowledge of a variety of accreditation organizations and programs
• Experience with a wide range of specialized management analysis tools and techniques and applying these skills on difficult and complex work assignments
• Skill in preparing project papers and staff reports and in organizing and delivering briefings to managers to encourage understanding and acceptance of findings and recommendations
• Inter personal skills in presenting recommendations and negotiating solutions to disputed recommendations
• Experience with pertinent laws - regulations - policies and precedents which affect the use of administrative and related support resources in the area studied
• Experience in major issues - program goals and objectives - and work processes of the organization
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/.

Duties

• The Accreditation Coordinator focus is on individual growth and development in practice with increased levels of self-direction and limited critical thinking skills
• Provides expertise and leadership in the areas of the facilities OIG healthcare inspections and related inquiries - TJC standards - Office of Accountability and Whistleblower Protection (OAWP) - the Office of the Medical Investigator (OMI) - CARF - LTC - Ascellon - and other internal and external survey programs
• Responsible for implementing and maintaining accreditation activities across the Southeast Louisiana Veterans Health Care System (SLVHCS)
• The Accreditation Coordinator has the responsibility for planning and coordinating continual regulatory compliance readiness activities throughout the Medical Center and Community Based Outpatient Clinics (CBOCs)
• Adheres to established policies - standards of care - and regulations
• Develops and participates in all aspects of Quality Improvement (QI) projects and implements QI when possible
• Utilizes a team approach when interacting with multidisciplinary teams and affiliates - and provides consultation to other units on individual patients and provides in-services for OIG and Regulatory related activities
• The Accreditation Coordinator serves on - or leads - committees - workgroups - and teams as assigned by management
• exercises control and continuing responsibility for projects - questions - or problems associated with the various compliance programs across the medical center
• The incumbent plays a critical support role in developing and coordinating internal review systems including tracers - audits - and mock surveys - to assure that both clinical and administrative programs are in compliance with agency - accrediting standards - and regulatory requirements
• Collaborates with leadership - unit managers - and frontline employees to identify accreditation related educational training needs for staff - while supporting activities that foster competence - critical thinking skills - and decision making
• Acts as a resource across departments/services-providing assistance and training as needed to both clinical and nonclinical staff
• Attends interdisciplinary meetings daily and attend any staff - national or VISN meetings 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 - Friday 08:00am - 04:30pm - Subject to changed based on the facility needs
• Telework: AD-Hoc only Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized