Registered Nurse - Accreditation/Readiness Coordination

Summary

The Accreditation/Readiness Coordination Registered Nurse (RN) leads accreditation and regulatory readiness programs across the Iowa City VA Health Care System, driving continuous compliance, survey preparedness, patient safety, and high-reliability practices to support exceptional Veteran care.

Duties

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being. The Accreditation/ Readiness Coordination Registered Nurse (RN) serves as coordinator for regulatory surveillance activities for the Iowa City VA Health Care System ICVAHCS and the Community Based Outreach Clinics (CBOCs) aligned under this facility. The Readiness Coordinator plays a critical role in supporting the efforts to ensure the medical center is meeting regulatory standards and provides oversight and consultative services toward organizational readiness for accrediting and monitoring organizations, which includes: The Joint Commission (TJC), Office of Inspector General (OIG), Annual Workplace Evaluation and Readiness (AWE), VA Self Inspections, and other external reviews. Promotes a culture of high reliability and safety within the system and partners with clinical and operational support staff to assure that standards and regulatory requirements are met in an environment of continual readiness efficacy. Continually evaluates and improves processes, activities, learning, and communication within these programs. Duties of the Accreditation/Readiness Coordination RN include, but are not limited to: Assists in the coordination of accreditation program specific reviews and preparation for internal and external reviews. Conducts systematic reviews of assigned clinical processes. Assists with ongoing tracer activities. 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. Backup for QMO. 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. Coordinates the annual Joint Commission Focused Standards Assessment (FSA) process, OIG inspection Issue and guidance, and OIG CHIP Guide self-assessment. In addition, this position would assist with QSV analyst functions-chart reviews, tracers and inspections. Analyzing data, and assist with facilitating Improvement Team activity. Participates in the annual performance improvement plan in establishing improvement priorities and monitoring activities. 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. 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 - Friday: 8:00a.m. - 4:30p.m. Telework: ADHOC-May be authorized (Employee who Telework on an occasional, episodic, or short-term, and have completed required telework training and telework agreement). Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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. Preferred Experience: Regulatory and Performance Improvement experience preferred Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade