Registered Nurse(Performance Improvement Accreditation)

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 TJCs 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 VHAs 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 VALLHCSs 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 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

• 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.
• 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 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.)