Accreditation Nurse
Job Location:
San Francisco, CA - USA
Yearly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
This position is located in the Quality and Patient Safety office (QPS) with direct reporting to the Deputy Chief QPS at SFVAMC. The Accreditation Nurse serves as an integral member of the team applying specialized education knowledge and experience to develop implement and sustain approved accreditation and regulatory initiatives provide expertise in coordinating analyzing and evaluating accreditation regulatory VISN 21 and other improvement requirements.
he Accreditation Nurse assists with plans regarding the medical centers accreditation and review addition he/she conducts the ongoing Joint Commission Intra Cycle monitoring review within the framework of meeting Joint Commission standards organizational objectives customer needs enhancing teamwork and improving the medical centers overall efficiency and effectiveness. Duties include direct and indirect patient care such as:
- Develop policies guidelines and procedures for the medical center related to various review requirements and recommends policy changes respective to the Joint Commission standards.
- Works with QPS Leadership and Nurse Manager to develop programs for Joint Commission Continuous Readiness and other accreditation activities including preparing mock survey schedules following up with all actions related to mock surveys developing training materials and working with the patient safety managers to develop information about patient safety goals etc.
- Participates on the SFVA Survey Readiness Committee (SRC) prepares the agendas and meeting minutes tracks open survey findings and monitors action plans and sustainment data and issues identified in the SRC.
- Collaborates with other facility leaders to formulate the medical centers Performance Improvement Plan and the Joint Commission Intra-cycle monitoring which provides for a systematic hospital-wide approach to performance assessment involving the elements of strategic planning interdisciplinary team initiatives and service-level improvement activities.
- Solicit managerial/supervisory input to identify Joint Commission and other accreditation/ regulatory projects i.e. aligning organizational processes redesigning current processes reinforcing new practices as they relate to accreditation and/or regulatory reviews etc.
- Provide technical advice and assistance to management various committees individual services task forces team leaders and team members within the SFVAHCS concerning operating components of Joint Commission and other regulatory compliance programs holds monthly accreditation open office hours for all SFVAHCS employees.
- Coordinate Joint Commission training for employees at the SFVA including all CBOCs.
- Trains SFVAHCS employees who participate in survey logistics actions including logistics.
- Knowledge of all policies regulations requirements and related standards set by Joint Commission and any other regulatory or accrediting organizations.
- Assist in the Patient Safety Program by participating in and facilitating Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FEMA).
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 through Friday 8:00am-4:30pm
Telework: Not availableVirtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
- 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 ( Effective May 7 2025 drivers 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.
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 masters level bridge program in nursing who have completed coursework equivalent to a bachelors 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.)
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: I Level I
Preferred Experience:1. Demonstrated expertise in interpreting and applying accreditation and regulatory standards from The Joint Commission (TJC) Centers for Medicare & Medicaid Services (CMS) Commission on Accreditation of Rehabilitation Facilities (CARF) and other governing bodies.
2. Documented experience leading facility-wide survey readiness programs including coordination of mock surveys patient and system tracers and follow-up to external reviews or investigations.
3. Proficiency in data collection aggregation and analysis using software such as AMP Microsoft Excel and VA platforms to identify trends and support performance improvement initiatives.
4. Ability to provide consultation and education across interdisciplinary teams on accreditation requirements action plan development and sustained readiness practices.
5. Masters degree in Nursing or a related healthcare field and/or possession of a nationally recognized certification in quality patient safety or accreditation (e.g. CPHQ HACP) is highly desirable.
Salary for this position is dependent upon applicant qualifications.Reference: For more information on this qualification standard please visit Requirements: This position requires visual acuity keen hearing clear distinctive speech and manual dexterity. The position requires potentially long periods of combined walking standing stooping sitting bending pulling and pushing. The incumbent must be a mature flexible sensible individual capable or working effectively in stressful situation able to shift priorities based on needs of the organization. The incumbent may be required to travel occasionally. This position potentially requires flexibility in schedule and assignments. Telework is position dependent and appropriate approvals are required; telework is not guaranteed and incumbent must comply with all regulations relevant to telework agreements policies and processes. If a position requires driving incumbent is required to maintain compliance with all relevant policies and processes.
IMPORTANT: 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: 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:
This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38 and are not covered by the Schedule A excepted appointment authority.
If you are unable to apply online or need an alternate method to submit documents please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Under the Fair Chance to Compete Act the Department of Veterans Affairs prohibits requesting an applicants criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process visit Human Resources and Administration/Operations Security and Preparedness (HRA/OSP) at The Fair Chance Act.
Candidates should be committed to improving the efficiency of the Federal government passionate about the ideals of our American republic and committed to upholding the rule of law and the United States Constitution.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
Required Experience:
IC
