Summary

The RN Quality Management (QM) Consultant-Accreditations/Quality Sections Chief is a full-time confidential consultant/program manager and supervisor in the Quality and Patient Safety Service. S/he serves as the coordinator and point of contact for external accreditation/review procedures and activities. Accrediting bodies and review groups include the Joint Commission - Office of Inspector General - VISN 19 Inspection Teams - Commission on Accreditation of Rehabilitation Facilities - and Ascellon.

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/12703228
• 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: Supervisory experience in the the Federal Government
• Experience with accreditations/regulatory standards/requirements - Change Management certified preferred
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: The incumbent must be able to perform all activities of the position without restriction
• This position involves considerable standing - walking - stooping - bending - reaching - lifting and turning
• The work may involve pushing or lifting weight in excess of 50 pounds and going up and down flights of stairs
• Requires visual and auditory acuity at a level to provide safe and effective care
• Requires the individual to work for periods of time with arms above shoulder level or with the neck in a fully flexed or extended position and the ability to physically control or protect him/herself from physically abusive patients
• Requires the individual to travel in an automobile for several hours at a time.

Duties

• Serve as the organization's Accreditation Specialist and the Quality Section Chief - supervising various Quality and Patient Safety (QPS) Service programs/staff
• Demonstrate leadership - experience - and creative approaches to improvement in quality-of-care outcomes
• 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
• Program is defined as a substantial coordinated group of activities impacting patients and/or employees
• Assigned responsibility for their assigned quality management program area activities for the health care system - including all outlying locations
• Collect data - monitor staff compliance with relevant policies - directives - and standards - provide reports detailing trends - and provides direct staff support to all services in planning - designing - integrating - implementing - modifying - and administering - a comprehensive quality management program area
• Participate in several health care system councils - committees - and workgroups
• Perform duties directly contributing to the administrative management of a health care delivery system
• Serve as the organization's trusted agent to develop - implement - and sustain an organizational accreditation program and promote the culture of compliance in everyday practice throughout VA ECHCS - including but not limited to communicating relevant external accreditation/review
• Manage various forms of confidential Information including obtaining and submitting protected and confidential official complaints after direct consultation with ELT - maintain knowledge of regulatory changes and potential impacts on the organization - and proactively recommend/implement corrective action - including auditing of completion and sustainment - and represent the interest of VA ECHCS in consultations with labor organization representatives in the evaluation of various oversight functions
• Supervisory duties
• 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: 7:00 A.M
• - 3:30 P.M
• Monday - Friday Telework: No
• Virtual: This is not a virtual position.