The Jesse Brown VA Medical Center in Chicago, Illinois has an opening for an Accreditation Nurse Specialist. This position is part of the Executive Director Service line. 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. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 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). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. 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: 5 years of experience as a Registered Nurse Master's degree in nursing or related field Certified Professional in Healthcare Quality (CPHQ) Certified Joint Commission Professional (CJCP) 1-2 years' experience in Quality Management specifically working with Accreditation Extensive experience with accreditation and/or regulatory compliance Certification in Lean management (green belt or black belt training) Strong writing and communication skills Adaptable with changing priorities Knowledge in health care delivery and quality management/performance improvement principles Knowledge in areas of accepted standards and methods to include: health care delivery; documentation of patient care; evaluation of patient care; medical record analysis for appropriateness of safe care; systems theory; and data extraction, evaluation, and reporting techniques Excellent interpersonal skills including the ability to appropriately and courteously relate to internal and external customers to include but not limited to: QSV Team, Director's Office, VISN, JBVAMC employees; and the public health care community Ability to function in an independent and self-directed role Experience in accreditation preparation and driving systems change Skilled in the use of computer software including Microsoft Word, Excel, Access, Visio, and other statistical process tools 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 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years 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 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. 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: Walking, bending, stooping, and some lifting in the direct care of patients. There may also be extended periods of sitting. ["The Accreditation Nurse Specialist will be responsible for the ongoing development and maintenance of a continuous readiness program at JBVAMC (including telehealth, the community-based outpatient clinics, and other JBVAMC community programs) to ensure facility accreditation and compliance with external accrediting standards and internal performance expectations as delineated in VHA guidelines and directives. The incumbent will promote a culture of continuous readiness within an enterprise risk management framework, driving improvement and developing processes which support safe and efficient patient care delivery. Achievement of these responsibilities will require strong skills in the leading of both large and small interdisciplinary groups seeking systems improvement outcomes; teaching; writing; chart review; data extraction, evaluation, and trending; electronic data reporting, including development of spreadsheets, tables, and graphs; project management skill; presentation development; priority-setting and critical thinking skills. The Accreditation Nurse Specialist coordinates necessary activities with individuals/Services to obtain the information necessary to prepare for accrediting bodies and review groups including but not limited to: The Joint Commission (TJC), Office of Inspector General (OIG), Commission on Accreditation of Rehabilitation Facilities (CARF), Ascellon, Office of Medical Inspector (OMI), and VISN 12 and VA Central Office/Program Office Inspection Teams. The incumbent is responsible for working closely with Service and Healthcare Leadership to provide internal and external accreditation site visit support (TJC, OIG, CARF, Ascellon) including assisting in developing action plans based on internally identified deficiencies and external findings. He she is also responsible for the following: monitoring, trending, and analyzing data, interpreting TJC standards, interpreting VA Handbooks and Directives regarding Quality, Safety, and Value. The incumbent provides clinical expertise and consultation to assist in data driven decision making and performance improvement matters, conducts tracers and operational assessments, participates in the design and analysis of special studies to define the cause and scope of issues or trends, and assists in the identification of appropriate criteria for problem resolution. He/she will work closely with QSV staff and Service Chiefs or designee to develop and implement performance improvement plans and related activities for their respected areas. The incumbent facilitates and maintains a record tracking system for monitoring a variety of information, potential problem areas, and action plans; coordinates action plans for addressing opportunities for improvement. The incumbent may entail other duties as assigned by the Deputy Chief or Chief of QSV and require to travel to all sites within the JBVAMC to include CBOCs. He/she serves as a resource to clinical and administrative staff and supervisors in the interpretation and application of accreditation, legal, VHA, local and professional standards and guidelines (e.g., Nurse Practice Act, ANA, VHA Directives, TJC Standards, etc.) Per local policy, the RN is responsible for maintaining Basic Life Support (BLS) certification. 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: 7:30am - 4:00pm, Scheduling flexibility required. Telework: Available as determined by agency policy for highly qualified candidates. 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"]
The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,298 health care facilities, including 171 medical centers and 1,113 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.
