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.
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a. Demonstrates expertise in implementation of Accreditation standards for compliance necessary to meet organizational objectives for accreditation.
b. Assesses and evaluates documentation by programs and services for accreditation standards compliance, both internal and external hospital surveys.
c. Interpret standards to understand the intent or rational of the regulations.
d. Plans, organizes, and implements education programs that address improvement opportunities within the medical center for accreditation purposes.
e. 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.
f. 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
h. 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.
i. Assists with development of databases with members of clinical and non-clinical staff to identify patterns and trends.
j. Serve as a resource to Hospital staff for appropriate use performance improvement tools and data.
k. Performs other duties as assigned by the Director PI that are relevant to support a robust and comprehensive PI program.
l. 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
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
Basic Requirements:
Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
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.
Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period.
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.
Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
Job Type: Full-time
Pay: $83,200.00 - $141,500.00 per year
Schedule:
Ability to commute/relocate:
Experience:
License/Certification:
Work Location: One location
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