Summary

The Accreditation Manager functions as a clinical expert and executes positions responsibilities that demonstrate leadership - experience - and creative approaches to management of the VA Finger Lakes Continuous Accreditation Readiness Program. They demonstrate sound decision-making - judgement and possess excellent interpersonal skills.

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

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/12933867

Grade/Level Scope Education

Nurse 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/

Preferred Experience:

3-5 years clinical nursing experience

experience with accreditation

excellent written communication skills

organized

Physical Requirements:

A pre-employment physical evaluation is required for this position.

Duties

DUTIES MAY INCLUDE HOWEVER ARE NOT LIMITED TO THE FOLLOWING: Provide oversight and leadership for the continuous readiness program and activities across the healthcare facility

Supports the organization in ongoing survey readiness which includes compliance with standard consistent with such accreditation bodies as The Joint Commission - Long Term Care Survey - Commission on Accreditation of Rehabilitation Facilities (CARF) - Office of Inspector General - and Government Accountability Office (GAO) and others

The Accreditation Manager is qualified by education and experience to demonstrate leadership - experience and creative approaches to ongoing facility readiness and compliance with accreditation bodies

The Accreditation Manager is responsible for designing - implementing and maintaining a system for analyzing - trending and tracking action plans to comply with accreditation and programmatic standards to support the delivery of quality care

chairing the Accreditation Readiness Committee and Tracer Team

analyzing data - compiling findings - and clearly communication data systematically to assess need for improvement in organizational processes

demonstrates understanding of process improvement strategies a

• Provide oversight and leadership for the continuous readiness program and activities across the healthcare facility
• Supports the organization in ongoing survey readiness which includes compliance with standard consistent with such accreditation bodies as The Joint Commission - Long Term Care Survey - Commission on Accreditation of Rehabilitation Facilities (CARF) - Office of Inspector General - and Government Accountability Office (GAO) and others
• The Accreditation Manager is qualified by education and experience to demonstrate leadership - experience and creative approaches to ongoing facility readiness and compliance with accreditation bodies
• The Accreditation Manager is responsible for designing - implementing and maintaining a system for analyzing - trending and tracking action plans to comply with accreditation and programmatic standards to support the delivery of quality care
• chairing the Accreditation Readiness Committee and Tracer Team
• analyzing data - compiling findings - and clearly communication data systematically to assess need for improvement in organizational processes
• demonstrates understanding of process improvement strategies a

• excellent written communication skills
• organized
• leadership
• experience
• creative approaches to management
• sound decision-making
• judgement
• excellent interpersonal skills
• process improvement strategies

• Proficiency in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by ACEN or CCNE
• 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
• 3 years of experience
• Experience with accreditation
• Associate Degree (ADN) or Diploma in Nursing OR Bachelor of Science in Nursing (BSN) OR Master's degree in nursing (MSN) OR Master's degree in a related field with a BSN OR Doctoral degree in Nursing OR Doctoral degree in a related field with a BSN