SummaryThe RN(Performance Improvement Accreditation) is responsible to the Deputy Chief, Quality and Patient Safety Service, who is directly responsible to the Chief of Quality and Patient Safety Service. The incumbent is responsible for consulting and providing leadership in the area of performance improvement, including facilitation of performance improvement projects, collecting, and analyzing data and assist with ongoing monitoring of metrics.
DutiesHelp
The Performance Improvement Accreditation Consultant will be responsible for providing leadership in the aspects of assessment, measurement, and process improvement including corrective actions regarding patient/resident care and organizational operations and functions across the continuum of care including but not limited to mental health inpatient and outpatient care areas as well as acute care settings. The incumbent will develop and coordinate facility-wide accreditation and Performance Improvement Plans demonstrating knowledge and the ability to apply principles of evidence-based practice. This would include utilizing TJC's AMP or AMP with Tracer programs in addition to traditional methods of the tracer program aligning practices with standards, guidelines, VHA directives and policies, research, and evidence. The PIA Consultant will fully embrace VHA's prescribed HRO foundational practices and HRO pillars of continuous process/learning improvement, culture of safety and leadership commitment as well as quality process/performance improvement methodology such as Lean or Lean Six Sigma Methodology, Rapid Cycle Improvement Strategies or Methodologies and the like in support or in collaboration with other QPS sections and service partners throughout the system. Demonstrating knowledge and the ability to apply principles of evidence-based practice. The incumbent will also teach NCPS Team Training courses as part of VALLHCS's cadre of Master Trainers and mentor teams in Team Training behaviors, concepts, initiatives, projects, and practices.
The Performance Improvement Accreditation Consultant will provide support and consultation at the unit, clinic, department, service, and organizational levels. Key responsibilities for the incumbent will be tracking, analyzing, and trending process activities including action plans or corrective actions in patient/resident care and organizational functions for continued survey and safety readiness including but not limited to TJC, OIG, OMI, CARF, ICC and other reviews or inspections at the VHA, VISN, state and local levels. The incumbent has the responsibilities as a Performance Improvement Accreditation Consultant for the development, implementation, and maintenance of the Quality and Patient Safety programs that include the delineation of standards and parameters of quality improvement in all aspects of patient care and operations impacting delivery of care.
The Performance Improvement Accreditation Consultant is accountable for the measurement of patient satisfaction and health outcomes and consequent collaborative action plan development; program development and implementation in continuous quality improvement (CQI) and total quality improvement (TQI), team building and personal development for CQI initiatives stemming from federal law and regulations, the Assistant Under Secretary for Health for Quality and Patient Safety (AUSHQPS) Office, VHA and VISN programs and directives impacting quality and safety, and process/performance improvement such as HRO, Strategic Planning and Priorities, Systems Redesign and Improvement, Strategic Analytics for Improvement and Learning Value Model (SAIL), CMS Star Rating and Hospital Compare Programs; and appropriate and judicious integration of patient, safety, risk management/mitigation and improvement across the care continuum and in all aspects of systems operations, and utilization of human and material resources.
The incumbent will be accountable for the measurement and health outcomes for the continuous survey readiness program and implementation in continuous quality improvement, personal development and team building for The Joint Commission Standards.The Performance Improvement Accreditation Nurse must be flexible at all times, assuming new responsibilities based on prioritization set forth by Executive Leadership. The incumbent will teach National Center for Patient Safety Team Training (NCPS TT) to all VA staff and providers. NCPS TT is a National Training Program that empowers all members of the clinical team to work together more effectively for patient safety and improve outcomes.
Preferred Experience:2-3 years healthcare accreditation experience
5+ Registered Nurse or other clinical discipline
Masters Degree in nursing or similar field preferred
Work Schedule: Monday thru Friday 8:00am-4:30pm. Tour subject to change depending on the needs of facility.
Telework: Not Available
Virtual: This is not a virtual position.
Financial Disclosure Report: Not required
RequirementsHelp
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.
QualificationsBasic 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.
- U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- 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/[redacted].
Grade/LevelScopeEducationNurse 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.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Physical Requirements: Heavy Lifting (45 lbs. and over); Moderate Carrying (15-44 lbs.); Pushing; Straight pulling; Pulling hand over hand; Reaching above shoulder; Use of fingers; Both hands required; Walking (up to 6 hours); Standing (up to 6 hours); Kneeling (Intermittent);Repeated bending (up to 6 hours); Both legs required; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13 " to 16"; Far vision correctable in one eye to 20/20 an to 20/40 in the other; Ability to distinguish shades of colors; Hearing (aid permitted); Emotional and Mental Stability.
EducationIMPORTANT: 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
Additional informationThis job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
