Summary The Accreditation Coordinator, Registered Nurse (RN), is responsible for utilizing the nursing process and practice principles to ensure the delivery of safe high-quality, patient-centered care at Veterans Health Care System of the Ozarks (VHSO), including all community-based outpatient clinics (CBOCs) within the facility catchment area located in Arkansas, Oklahoma, and Missouri. Responsibilities The Registered Nurse Accreditation Coordinator executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex patient care. The Nurse III registered nurse demonstrates performance and leadership that is broad enough to improve the care for a group of patients. The Nurse is responsible for the documented outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility, Veterans Integrated Systems Network (VISN), or Veterans Affairs Central Office (VACO). Program is defined as a substantial coordinated group of activities impacting patients and/or employees. Key relationships with staff, expert knowledge of The Joint Commission accreditation standards and rules and procedures in addition to maintaining a working knowledge of other external review procedures are needed to (1) assists with accurate submission of accreditation applications for new or expanded services in accordance with accreditation rules (2) support continuous readiness activities of the Health Care System (3) maintain accreditation standards compliance (4) identify and address trends and opportunities for improvement to contribute to ongoing accreditation and performance improvement (5) serve as a continuous accreditation readiness consultant for facility Quality Managers, Service Chiefs and their staff, and VHSO Leadership. Major Duties include, but are not limited to: - Assists in the coordination of accreditation program specific reviews and preparation for internal and external reviews. Assists in ensuring that processes are in place to meet the established standards of the accreditation organization or regulating body. - Conducts systematic reviews of assigned clinical processes. Assists and reviews ongoing tracer activities and keeps abreast of changes with new standards. - Maintains data components and records associated with assigned clinical reviews, which include the tracking and trending of data, aggregating into reports, ensuring compliance with established timeframes, and facilitating improvement action plans. - Provides consultation and guidance on clinical performance measures, assigned performance improvement clinical reviews, and use of performance improvement tools and techniques. - Facilitates the development and coordination of internal review systems to assure that both clinical and administrative activities are in compliance with agency, accrediting, and regulatory requirements. - Develop policy guidance, motivational materials, and information to facilitate staff compliance with required standards. - Participates in the annual performance improvement plan in establishing improvement priorities and monitoring activities. - Demonstrates understanding of priorities and how individuals contribute to overall VHA and facilities strategic mission/goals and objectives. - Provides Readiness education and partners with education and management to embed continual readiness and high reliability approaches in department/unit activities and processes. - Provides consultation to assure continuous improvement and progress toward improving readiness and high reliability. - Collaborates with organizational leadership and staff to assure that regulatory patient safety standards are met or exceeded. - Proactively identifies high risk/out of compliance areas, establishes communications and action plans to address, partners with operations to establish internal controls, implement resolutions, and measure outcomes. - Proficient in preparing reports and data to assure resources are efficiently and effectively used in the provision of safe, high quality, patient centered care. - Evaluates available options and selects a course of action which will result in the safest and most favorable patient or organizational outcomes. - Demonstrates knowledge and skills to maintain expertise in area of practice. - Demonstrates proficiency in computer literacy. 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, Monday - Friday Telework: Available (Ad-hoc) Virtual: This is NOT a virtual/remote position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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. 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/12860678. 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: Effective prioritization skills to manage multiple ongoing tasks Flexibility/Resiliency to complete daily tasks and impromptu assignments Minimum of 3-5 years of professional nursing experience Knowledge of Performance Improvement tools and practices Quality Management experience preferred Vast knowledge of Accreditation program to include Joint Commission, OIG, CARF, and other accrediting bodies, healthcare system policies, VHA directives, and organizational standards Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: Light lifting and carrying - under 15lbs, reaching above shoulder, use of fingers, working closely with others, working alone. Education Additional Information This job opportunity announcement may be used to fill additional vacancies. 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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
