Accreditation Nurse

<p>This position is located in the Quality and Patient Safety office (QPS) with direct reporting to the Deputy Chief QPS at SFVAMC. The Accreditation Nurse serves as an integral member of the team applying specialized education, knowledge, and experience to develop, implement and sustain approved accreditation and regulatory initiatives, provide expertise in coordinating, analyzing, and evaluating accreditation, regulatory, VISN 21 and other improvement requirements.</p><h3>Major Duties</h3><p>he Accreditation Nurse assists with plans regarding the medical center's accreditation and review programs. In addition he/she conducts the ongoing Joint Commission Intra Cycle monitoring review within the framework of meeting Joint Commission standards, organizational objectives, customer needs, enhancing teamwork, and improving the medical center's overall efficiency and effectiveness. Duties include direct and indirect patient care such as: Develop policies, guidelines, and procedures for the medical center related to various review requirements and recommends policy changes respective to the Joint Commission standards. Works with QPS Leadership and Nurse Manager to develop programs for Joint Commission Continuous Readiness and other accreditation activities including preparing mock survey schedules, following up with all actions related to mock surveys, developing training materials, and working with the patient safety managers to develop information about patient safety goals, etc. Participates on the SFVA Survey Readiness Committee (SRC), prepares the agendas and meeting minutes, tracks open survey findings and monitors action plans and sustainment data and issues identified in the SRC. Collaborates with other facility leaders to formulate the medical center's Performance Improvement Plan and the Joint Commission Intra-cycle monitoring which provides for a systematic, hospital-wide approach to performance assessment involving the elements of strategic planning, interdisciplinary team initiatives, and service-level improvement activities. Solicit managerial/supervisory input to identify Joint Commission and other accreditation/ regulatory projects, i.e., aligning organizational processes, redesigning current processes, reinforcing new practices, as they relate to accreditation and/or regulatory reviews, etc. Provide technical advice and assistance to management, various committees, individual services, task forces, team leaders, and team members within the SFVAHCS concerning operating components of Joint Commission and other regulatory compliance programs, holds monthly accreditation open office hours for all SFVAHCS employees. Coordinate Joint Commission training for employees at the SFVA , including all CBOCs. Trains SFVAHCS employees who participate in survey logistics actions, including logistics. Knowledge of all policies, regulations, requirements and related standards set by Joint Commission and any other regulatory or accrediting organizations. Assist in the Patient Safety Program by participating in and facilitating Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FEMA). 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, 8:00am-4:30pm Telework: Not availableVirtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required</p><h3>Requirements</h3>U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.<h3>Education</h3>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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.