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    The Accreditation Manager/Quality Management Specialist duties include specialized roles and responsibilities of the Quality Management Programs of Accreditation: Regulatory Compliance and Regulatory readiness aligned with Performance Improvement, Risk Management, Patient Safety, and advise/provide leadership to VA on program implementation and evaluation of policies and objectives.

    Applicants must upload a copy of their SF-50 to qualify as an internal VA Boston/VHA employee.

    Learn more about this agency


    Accreditation Coordinator: Responsible for continuous readiness of VA Boston Healthcare System for accreditation and regulatory agency review and compliance (Joint Commission, Inspector General, Long Term Care Institute, etc.); performance and quality measures; and program monitors and actions. Serves as point of contact and primary support (logistics such as arranging workspace and meals and coordinating staff for interviews) for site visitors engaged in the accreditation process. Manages processes related to survey readiness, IPEC monitors, SAIL data, EPRP data, tracers, chart reviews, and environment of care surveillance. Compiles regulatory data and communicates information to VABHS leadership in a format that is conducive for utilization in decision making, strategic planning and performance improvement. Chairs monthly meetings in support of deploying a systematic approach to readiness and integrating readiness activities in all areas. Rounds frequently to work with staff at the unit-level on accreditation readiness issues. Troubleshoots issues related to quality of care and provides real time feedback to leadership. Responds on site in real time as incidents occur to investigate and prepare follow-up reports during administrative hours; follows-up next administrative day on occurrences during non-administrative tours.

    Quality Management Specialist: The incumbent is responsible for supporting deployment of the Baldrige Excellence framework and the organizational Performance Improvement System; for administering the performance improvement on a day to day basis, managing, interpreting, and analyzing data and performance measures; participates in relevant hospital committees and functions that support the cascading of performance measures from Control Room to Huddle board.
    Incumbent tracks, analyzes, and trends regulatory action plans and monitors for sustainment of improvement. May participate in root cause analysis, peer review, Lean Six Sigma teams, EPRP monitors, and employee surveys. Works in collaboration with the Patient Safety and Risk Management for tracers and chart reviews.

    The incumbent collaborates with Risk Managers to systematically identify, evaluate, reduce and/or eliminate, and monitor the occurrence of adverse events and situations arising from operational activities and environmental conditions. This process frequently involves collaboration with other disciplines such as Patient Safety and Patient Experience. The utilization of strong administrative, organizational and communication skills while applying high standards for privacy and ethical considerations, is required on a daily basis. The incumbent may conduct investigations, audits, and problem focused studies which include record reviews, collecting relevant data, analyzing all aspects and making recommendations to mitigate risks; conducts processes associated with organizational investigations, such as AIB (Administrative Investigative Boards) and tort claim processing, and peer review; and advises/consults with management to ensure that the results are fully integrated in the overall Quality Management program.

    Theincumbent promotes and supports a culture of safety throughout the organization. Works collaboratively with all members of the clinical team to disseminate Joint Commission National Patient Safety goals to all employees and to facilitate assimilation into daily practice. Provides clinical and administrative recommendations in relation to the Patient Safety Function.

    Work Schedule: Monday - Friday, 7:30 am to 4:00 pm to include travel among all facilities and CBOCs
    Financial Disclosure Report: Not required

    Travel Required

    Occasional travel - You may be expected to travel for this position.

    Supervisory status


    Promotion Potential


  • Job family (Series)

    0610 Nurse

This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/580000700. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.