The Regulatory Specialist is responsible to ensure the achievement of accreditation standards ,compliance initiatives necessary to meet organizational objectives for accreditation by coordinating, developing, implementing, monitoring, and evaluating these activities throughout the facility in order to attain and maintain full accreditation status. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: The population of male and female veterans served ranges from the adult, age 18, to the elderly adult, age 65 and over. This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing. Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs. See VA Directive and Handbook 5019. ["VA offers a comprehensive total rewards package: VA Nurse Total Rewards a. Demonstrates expertise in implementation of Accreditation standards for compliance necessary to meet organizational objectives for accreditation.\nb. Assesses and evaluates documentation by programs and services for accreditation standards compliance, both internal and external hospital surveys.\nc. Interpret standards to understand the intent or rational of the regulations.\nd. Plans, organizes, and implements education programs that address improvement opportunities within the medical center for accreditation purposes.\ne. Actively participates in the performance improvement process by assisting with the identification of opportunities for improvement that create safe, efficient and streamlined processes and promote positive patient outcomes.\nf. Assists with hospital preparation for accrediting and regulatory surveys and reviews by assessing Hospital compliance with standards and through staff education with regard to regulatory and accrediting standards. Coordinating Mock Tracers for Joint Commission Readiness throughout the facility g. Actively participates in Hospital Failure Mode Effect Analysis and performance improvement teams by facilitating meetings, conducting fact finding reviews and/or investigations, developing action plans, maintaining meetings and coordinating follow-up actions.\nh. Assists with the coordination of Hospital and Support Services Performance improvement Committee and Sub- Committees to include identification of relevant topics for discussion, agenda preparation, preparation of meeting materials, and minute preparation.\ni. Assists with development of databases with members of clinical and non-clinical staff to identify patterns and trends.\nj. Serve as a resource to Hospital staff for appropriate use performance improvement tools and data.\nk. Performs other duties as assigned by the Director PI that are relevant to support a robust and comprehensive PI program.\nl. Assists, collaborates, and shares information with people in other departments or units when appropriate Work Schedule: Monday to Friday, 7:30 am to 4:00 pm\nTelework: Not Available\nVirtual: This is not a virtual position.\nRelocation/Recruitment Incentives: Not Authorized\nPermanent Change of Station (PCS): Not Authorized\nFinancial Disclosure Report: Not required"]
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.