Full Job Description
The incumbent is responsible for developing and implementing a proactive and systematic approach to accreditation readiness. The Quality Management Accreditation Specialist frequently interacts with medical center leadership including service chiefs, middle managers and employees in staff positions. He or she also interacts with employees of outside accrediting bodies, community healthcare entities, and VHA employees from the Network and other agencies.
Responsible for ensuring new standards or changes to standards are communicated and implemented timely to meet TJC accreditation;
Coordinate and conduct ongoing tracers and other activities to proactively keep leaders and staff knowledgeable on the responsibilities and requirements of any external review;
Serves as a consultant to leadership, functional teams, QM staff, and all other staff regarding accreditation issues. He/she stays abreast of changes related to the requirements and standards, presents timely updates of information and insures leadership and all key individual having responsibility are informed;
Prepares and implements strategy and plans designed to meet regulatory and accreditation requirements for Continuous Readiness Program including the use of available Accreditation Tools, TJC Connect and VHA VISN and National websites;
Serves as a Joint Commission and OIG Subject Matter Expert with comprehensive and authoritative knowledge of the Joint Commission, OIG, and other regulatory standards and survey process; providing guidance, instruction, direction and leadership across multiple clinical teams for achieving quality outcomes for patients and successful accreditation surveys;
Provides guidance and oversight to assigned services/programs to ensure compliance with VHA Handbooks/Directives and accreditation standards;
Evaluates, identifies, investigates, and brings forward issues of potential concern or opportunity related to operational performance and access and develops Performance Improvement tools to meet specific operational needs of assigned services/programs;
Establishes and facilitates performance improvement interdisciplinary teams across the organization;
Serves as an active participant for numerous Medical Center Committees, or Collaborative Workgroups most relevant to assigned services/programs or clinical expertise;
Complete daily occurrence screens, tracers, action items, Fact Findings, and other investigations related to OIG or other complaints.
Work Schedule: Monday - Friday 7:30 a.m. to 4:00 p.m. OR 8:00 a.m. to 4:30 p.m.
Financial Disclosure Report: Not required
Relocation/Recruitment Incentives: Not Authorized
Telework: Not Authorized
Virtual: Not Authorized
Job family (Series)
Conditions of Employment
You must be a U.S. Citizen to apply for this job
Designated and/or random drug testing required
Selective Service Registration is required for males born after 12/31/1959
You may be required to serve a probationary period
Subject to a background/security investigation
Must be proficient in written and spoken English
Selected applicants will be required to complete an online onboarding process
Must pass pre-employment physical examination
Must possess current, unrestricted license as a Registered Nurse
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.
United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
Graduate of a school of professional nursing approved by the appropriate State-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). 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.
Preferred Experience: Progressive experience in clinical and administrative management with a minimum of five years of increasingly complex nursing practice in clinical settings; Quality Management/Accreditation Readiness experience preferred.
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 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's 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 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience.
Physical Requirements: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires heavy, moderate, and light lifting of 15-45 pounds or more. This position requires potentially prolonged periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing for up to 8-12 hours. Transferring patients and objects may be required. 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.
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.
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.
Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period.
This job opportunity announcement may be used to fill additional vacancies.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
If you are unable to apply online view the following link for information regarding an Alternate Application.
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
NOTE: Candidate's education and length of nursing practice (experience) will be considered by a Nurse Professional Standards Board in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.
Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following four dimensions of nursing: Practice, Professional Development, Collaboration and Scientific Inquiry. Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
Background checks and security clearance
Drug test required
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Trust determination process
To apply for this position, you must provide a complete Application Package which includes:
VA Form 10-2850a
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
DD-214/ Statement of Service
Disability Letter (VA)
VA Form 10-2850a
SF-50/ Notification of Personnel Action
A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.
This job is open to
Federal employees - Competitive service
Current or former competitive service federal employees.
Federal employees - Excepted service
Current excepted service federal employees.
Internal to an agency
Current federal employees of this agency.
U.S. citizens, nationals or those who owe allegiance to the U.S.
Clarification from the agency
The Area of Consideration will be: 1st Area of Consideration - Current Michael E. DeBakey VA Medical Center Facility and CBOC employees. 2nd Area of Consideration - VA Nationwide applicants. 3rd Area of Consideration - All other eligible candidates.