Registered Nurse Accreditation Specialist (QPS)

SummaryThe 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.QualificationsBasic Requirements:English Language ProficiencyIn 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 EnglishGraduate 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 programUpon 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 programCredit 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 ColumbiaGraduate 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/certificationGrade 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 gradeThe 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/12953688Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competenciesAn Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing requiredNurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complexAn 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 requiredNurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planningSelf-directed in goal setting for managing complex client situationsAn ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2OR a Master's degree in nursing (MSN) and no additional professional nursing experienceOR a Master's degree in a *related field with a BSN and no additional professional nursing experienceNurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with othersA BSN with 2 years of professional nursing equivalent to Nurse I - Level 3OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3OR a Doctoral degree in Nursing with no professional nursing experienceOR a Doctoral degree in a *related field with a BSN with no additional professional nursing experienceNurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice settingMSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse IIIOR 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 IIIOR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse IIIOR 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 degreesReference: 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 pushingreaching above shoulderuse of fingersboth hands requiredwalking and standing up to 8 hoursrepeated bendingAbility for rapid mental and muscular coordination simultaneouslyhearing aid permitted.DutiesThe 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 centerThe incumbent functions independently in a fast-paced - highly visible role that requires exceptional communication - coordination - and the ability to manage multiple competing prioritiesMajor 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 dataidentify system-level risksand 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 reliabilityVA 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 organizationTelework: Not Available Virtual: This is not a virtual positionRelocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required