- Coordinates organizational readiness activities/process for survey by Joint Commission (TJC), Office of the Inspector General (OIG), Commission on Accreditation of Rehabilitation Facilities (CARF), and other external reviews.
- Organizes and conducts system and patient tracers across the organization, communicates opportunities to local management, and aggregates tracer findings to report through the governance structure.
- Coordinates the distribution of new VHA Clinical Directives/Handbooks. Assists local staff in conducting gap analysis and action plans to meet new requirements in Directives/ Handbooks.
- Tracks action items to completion.
- Consult with staff and management on ideas for standards/regulatory compliance. Translates regulatory and accrediting body standards, policies, and strategies into action within the facility.
- Advises staff and management of relevant standards and evaluates situations for standards/regulatory compliance. Completes annual reports and data submissions, coordinators document submissions, and tracks external review recommendations to completion.
- Evaluate previously closed actions for sustained compliance.
- Educates staff across the medical center on standards and regulations relevant to care provided and changes in standards and regulations.
- National Patient Safety Goals: Reviews, Updates, developing tracking method for the facility.
- Participate in VISN Accreditation Meetings
- Performs other duties as assigned.
Registered Nurse - Kansas City, United States - Department Of Veterans Affairs
Description
Summary
The Kansas City VA Quality Department is looking for a 120-day detail into the Quality Management / Accreditation Manager position.
The Accreditation Coordinator is registered nurse accountable for coordination, development and implementation of programs and activities that ensure compliance with standards set forth by accrediting bodies and surveying agencies.
Duties
The Quality Management (QM)/ Accreditation Manager (AM)/ Registered Nurse (RN). The QM/AM Manager is responsible for the documented outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility. A program is defined as a substantial coordinated group of activities impacting patients and/or employees.
The QM/AM is responsible for their assigned quality management program area activities for the Medical Center and all off-site locations. The QM/AM collects data, monitors staff compliance with relevant policies, directives, and standards, provides reports detailing trends, and provides direct staff support to all services in planning, designing, integrating, implementing, modifying, and administering, a comprehensive quality management program area. They participate in several facility councils, committees, and workgroups.
Execute the position responsibilities that demonstrate effective leadership, detailed planning, professional communication, creative and innovative approaches to the improvement of safety/healthcare program development and possess an ability to organize priorities.
Major Job Duties:
VA offers a comprehensive total rewards package: VA Nurse Total Rewards
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
Telework: Ad-Hoc
Temporary Detail: NTE 120 Days
Financial Disclosure Report: Not required