Accreditation Assessment Officer, Laboratory Medicine, Diagnostic Accreditation Program

Full-time, permanent
Position summary
Reporting to the manager, laboratory medicine, the accreditation assessment officer (AAO), laboratory medicine, is responsible for assessing the performance of the laboratory medicine facilities/services of British Columbia for the purposes of awarding accreditation.
Through on-site assessments of the laboratory medicine facility/service, the AAO writes assessment reports identifying best practices evidenced, opportunities for improvement, and follow-up actions required to address identified nonconformances. In conducting the assessments, the AAO provides education and shares best practices for the purposes of improving quality and safety.
In the capacity of accreditation assessment officer, this position has delegated authority to review and sign off on evidence submitted in response to identified nonconformances, and to make recommendations for accreditation awards to the Diagnostic Accreditation Program (DAP) Committee.
The position requires regular travel outside of the Lower Mainland for two to three days at a time.
Duties and responsibilities
Duties include but are not limited to the following:
• assess the performance of the laboratory medicine facilities services of British Columbia for the purposes of awarding accreditation
◦ evaluate the laboratory medicine facility’s/service’s level of actual performance to achieving the DAP accreditation standards
◦ review and evaluate desktop audit submissions
◦ conduct on-site visits to the laboratory medicine facility/service
• perform pre-assessment activities
◦ answer queries from laboratory medicine facilities/services related to the interpretation and the application of DAP accreditation standards
◦ assist in the development of an accreditation strategy and schedule for each laboratory medicine facility/service including reference to any regional/corporate structure models
• perform on-site assessments
◦ review and evaluate evidence submissions from laboratory medicine facilities/services in accordance with DAP assessment policies and procedures
◦ conduct on-site assessments in accordance with DAP assessment policies and procedures
◦ follow up with laboratory medicine facilities/services, as required, for further information or clarification of submitted information
◦ provide education and share best practices for the purposes of assisting the laboratory medicine facility/service to continually improve safety and quality
• perform post-assessment activities
◦ prepare reports resulting from the on-site assessments
◦ identify nonconformances to be addressed by the laboratory medicine facility/service with associated time frames for completion
◦ perform the technical quality review of the report for the other laboratory medicine, accreditation assessment officer
◦ submit reports to the manager, laboratory medicine within the time frame defined in the DAP service standards
◦ make recommendations to the DAP Committee on the appropriate level of accreditation award for the laboratory medicine facility/service assessed
• perform the activities of an accreditation officer
◦ conduct initial assessments of new laboratory medicine facilities/services and prepare initial assessment reports
◦ conduct focused visits as required and develop focused assessment reports documenting findings from the focused visit and any recommended courses of action
◦ conduct focused desktop assessments as required and develop focused assessment reports documenting findings from the focused visit and any recommended courses of action
◦ review submissions from laboratory medicine facilities/services in response to cited nonconformances and determine whether the laboratory medicine facility/service has demonstrated compliance to the accreditation standard
◦ review extension request submissions from laboratory medicine facilities/services in response to cited nonconformances and determine whether the timeline to the cited nonconformance can be extended as per request.
◦ follow up directly with the facility as required to clarify information or ask for additional information
◦ document the assessment of demonstrating compliance to a cited nonconformance, or a recommended course of action to be taken by the laboratory medicine facility/service
◦ communicate and work effectively with the manager, laboratory medicine and accreditation specialist as it relates to these assigned duties
◦ provide reports and documentation in a timely and prescribed manner to the manager, laboratory medicine
• other general duties
◦ assist with the maintenance of facility profiles, key contact lists, etc. to ensure information is current, accurate and reliable
◦ assist in the continuous development and maintenance of accreditation methodologies, standards, protocols, processes and tools
◦ participate in communication and representation activities
◦ facilitate meetings, forums, focus groups and workshops
◦ contribute to the development and maintenance of educational programs
◦ deliver educational programs assigned
◦ attend meetings and functions at the direction of the manager, laboratory medicine
◦ assist in the achievement and maintenance of accreditation awards from international accreditation bodies, including ISQua and APAC
◦ perform related duties as assigned
Decision-making
The accreditation assessment officer
• identifies best practices, opportunities for improvement, and follow-up actions required to address identified nonconformances, and
• makes recommendations for accreditation awards to the responsible accreditation program committee.
Accountability
The accreditation assessment officer:
• informs the manager, laboratory medicine of any quality, safety or other risk issues related to accreditation assessment activities and ensures that any potential hazards and risks to patients and/or staff are recognized and minimized
• evaluates the activities of diagnostic facilities
• understands and responds to the requirements of facilities as they relate to the accreditation requirements
• participates in the improvement activities for quality and safety processes provided through the Accreditation Programs quality improvement program
• follows the policies and procedures of the College of Physicians and Surgeons of BC
• provides timely reports to the manager, laboratory medicine when requested
Skills and qualifications
Required skills and qualifications include:
• medical laboratory technologist with certification from the Canadian Society of Medical Laboratory Science (CSMLS)
• graduation from a recognized post-secondary institution in a health-related discipline and/or five years of experience working in a health service/system
• experience working with quality systems and accreditation programs
• experience in data collection, review, synthesis, and the qualitative and quantitative analysis of data
• completion of a program and/or courses in quality management from a recognized post-secondary institution
• evaluation and critical thinking skills
• exceptional client service skills
• facilitation of large groups
• excellent communication skills, written and oral
• ability to deliver education and orientation programs utilizing a variety of recognized adult education methodologies
• professional and business-like manner
• possession of a valid BC driver’s licence
• ability and willingness to drive and travel
The compensation range for this position is $87,392 to $109,240 per year.


We thank all applicants for their interest. Once submitted, a member of the Human Resources team will be in touch. If you have any questions, please email humanresources@cpsbc.ca.
The College of Physicians and Surgeons of BC (CPSBC) is committed to our ongoing journey to be a diverse, equitable and inclusive place to work. All interested applicants, regardless of age, family or marital status, physical or mental disability, race, colour, religion, place of origin, and ancestry, Indigenous identity, gender identity or expression, sex, sexual orientation political belief, socio-economic background, criminal conviction or any other characteristic protected by applicable law, are strongly encouraged to apply. Accommodations are available upon request for candidates taking part in the recruitment and selection process.
CPSBC is located on the unceded and traditional territory of the Coast Salish peoples, including the territories of the hən̓q̓əmin̓əm̓ speaking peoples―the xʷməθkʷəy̓əm (Musqueam) and sel̓íl̓witulh (Tsleil-Waututh) Nations, and the Sḵwx̱wú7mesh-ulh Sníchim speaking peoples―the Sḵwx̱wú7mesh (Squamish) Nation.

We acknowledge the rights and title of BC First Nations whose territories span across the province. These territories recognize that laws, governance, and health systems tied to lands and waters have existed here since time immemorial.