The Registered Nurse Accreditation Specialist is assigned to the Quality and Patient Safety (QPS) Service and reports to the Deputy Chief - QPS at the Long Beach VA Healthcare System.
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/12953688
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/
Physical Requirements: Heavy lifting (45 lbs and over)
Heavy carrying (45 lbs and over)
Straight pulling and pushing
reaching above shoulder
use of fingers
both hands required
walking and standing up to 8 hours
repeated bending
Ability for rapid mental and muscular coordination simultaneously
hearing aid permitted.
Duties
The RN Accreditation Specialist is a key nursing leader who partners closely with Service Chiefs - Healthcare Group Leadership - and interprofessional teams to drive continuous survey readiness and high-reliability care across the medical center
The incumbent functions independently in a fast-paced - highly visible role that requires exceptional communication - coordination - and the ability to manage multiple competing priorities
Major Duties and Responsibilities - Leads and manages the facility's continuous readiness and accreditation program - ensuring ongoing compliance with federal regulatory requirements - internal review processes - and external accreditation standards (OIG - TJC - Ascellon - and other oversight bodies)
- Serves as a primary liaison with accreditation and regulatory organizations - coordinating site visits - tracers - document submissions - and follow-up actions in collaboration with executive leadership - services - and facility committees
- Collaborates closely with the Patient Safety Manager - Risk Management - Infection Prevention - High Reliability Organization - Systems Redesign - and other quality and clinical leaders to monitor - trend - and analyze data
identify system-level risks
and drive timely completion of corrective actions and performance improvement initiatives
- Interprets and operationalizes The Joint Commission standards - VA Handbooks and Directives - and VHA quality - safety - and performance improvement requirements - translating complex regulatory language into practical expectations for frontline staff and leaders
- Utilizes a comprehensive - organized - continuous readiness framework to proactively assess clinical and administrative processes - conduct tracers and operational assessments - and identify opportunities to improve quality - safety - and patient experience
- Provides expert clinical and regulatory consultation to leadership and care teams - supporting data-driven decision making - development of action plans - and evaluation of outcomes for quality - performance improvement - and patient safety projects
- Designs - participates in - and analyzes audits to define the cause and scope of identified issues or trends and recommends evidence-based - sustainable solutions
- Plans - leads - and facilitates effective communication and education related to accreditation and regulatory requirements - ensuring that staff at all levels are informed - engaged - and prepared for unannounced surveys and focused reviews
- Coordinates and tracks progress of reviews - corrective action plans - and follow-up items across multiple services and programs - ensuring accountability - documentation - and completion within required timeframes
- Builds strong collaborative relationships with Medical Center leadership - service chiefs - managers - and frontline staff to foster a culture of continuous improvement - transparency - and high reliability
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 Preferred Experience: 3-5 Years of acute medical/surgical experience Master's Degree in nursing or related field 3-5 Years of quality management - performance improvement experience Experience interpreting and implementing accreditation and regulatory standards (OIG - TJC - and Ascellon) Excellent interpersonal skills and ability to work independently as well as collaboratively with multiple service lines Work Schedule: 7:30AM to 4:00PM Work schedule is subject to change based on the needs of the organization
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
The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.