Summary 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. Responsibilities 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 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/13006127. 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:1. Demonstrated expertise in interpreting and applying accreditation and regulatory standards from The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Commission on Accreditation of Rehabilitation Facilities (CARF), and other governing bodies. 2. Documented experience leading facility-wide survey readiness programs, including coordination of mock surveys, patient and system tracers, and follow-up to external reviews or investigations. 3. Proficiency in data collection, aggregation, and analysis using software such as AMP, Microsoft Excel, and VA platforms to identify trends and support performance improvement initiatives. 4. Ability to provide consultation and education across interdisciplinary teams on accreditation requirements, action plan development, and sustained readiness practices. 5. Master's degree in Nursing or a related healthcare field, and/or possession of a nationally recognized certification in quality, patient safety, or accreditation (e.g., CPHQ, HACP) is highly desirable. Salary for this position is dependent upon applicant qualifications. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. The position requires potentially, long periods of combined walking, standing, stooping, sitting, bending, pulling, and pushing. The incumbent must be a mature, flexible, sensible individual capable or working effectively in stressful situation, able to shift priorities based on needs of the organization. The incumbent may be required to travel occasionally. This position potentially requires flexibility in schedule and assignments. Telework is position dependent and appropriate approvals are required; telework is not guaranteed and incumbent must comply with all regulations relevant to telework agreements, policies, and processes. If a position requires driving, incumbent is required to maintain compliance with all relevant policies and processes. Education 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/. 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.
