Accreditation and Research Development Officer, Laboratory Medicine, Diagnostic Accreditation Program

Full-time, permanent

Position summary

Reporting to the manager, laboratory medicine, the accreditation and research development officer, laboratory medicine’s primary responsibility is conducting research and evaluating, maintaining and developing the diagnostic accreditation program (DAP) standards for laboratory medicine. In addition, the position also contributes to the research of, and evaluation, maintenance and development of cross-specialty/common issues and programs. 

This position also participates in laboratory medicine facility accreditation assessments including writing assessment reports, identifying best practices evidenced, opportunities for improvement, and follow-up actions required to address identified nonconformances.

Duties and responsibilities

Duties include but are not limited to the following:

• develop and maintain accreditation standards for laboratory medicine through research, development, testing and evaluation
  
  • identify objectives and timeframes for standards development
  • ensure integrity across existing programs
  • draft standards, criteria, criteria descriptors, reference material, risk levels, and mandatory requirements timelines
  • support the development of assessor protocols and other assessment tools (e.g. initial assessment and focused visit protocols)
  • participate in the development of associated educational and supporting material
  • ensure that transitional arrangements for implementation of revised standards are identified and followed
  • document procedures for the review, revision and development of standards
  • develop tools for standards evaluation and improvement
• develop and maintain accreditation programs for disciplines related to laboratory medicine
  
  • conduct formal review processes and identify the need for new or revised standards
  • identify objectives and timeframes for new program standards development
  • identify and propose parameters for the programs
  • ensure consistency and integrity across existing and new programs
  • analyze and synthesize feedback and evaluation for the purpose of proposing program improvements
  • develop program criteria, assessor protocols, other assessment tools and associated educational and supporting material
  • develop theoretical assessment frameworks for consideration
• perform program-specific analysis to support decision-making and system-wide improvement
  
  • collect data from accreditation assessment processes for the purposes of review, synthesis, qualitative and quantitative/statistical analysis of data, leading to the development of reports indicating significant trends
  • continuously review literature and other sources of information related to laboratory medicine
  • consult and communicate with field experts and community partners using methodology appropriate to the exercise
  • identify and analyze issues, assessing significance, and submitting recommendations for resolution
  • formulate policy positions and draft policy papers for consideration
• chair assigned advisory committee meetings
  
  • prepare advisory committee meeting agendas for review and approval by the committee members
  • prepare associated briefing notes for distribution with the final agenda
  • ensure the completion and accuracy of all documents forwarded to the advisory committees
  • ensure advisory committees’ advice and decisions are implemented into the accreditation standards for laboratory medicine in a timely and effective manner.
  • maintain a record of decisions made by the advisory committees, minutes, agenda and briefing notes
• perform the activities of an accreditation officer
  
  • conduct assessment activities, including full assessments, initial assessments of new diagnostic service facilities and relocation assessments
  • review submissions from diagnostic service facilities in response to nonconformances and determine whether the facilities have fulfilled the nonconformance
    
    • follow up directly with the facility as required to clarify information or ask for additional information 
  • document the assessment of fulfilling the nonconformance, or a recommended course of action to be taken by diagnostic service facilities 
  • communicate and work effectively with the manager, laboratory medicine and accreditation specialist as it relates to these assigned duties
  • review and sign-off on evidence submitted in response to nonconformance submissions and to make recommendations for accreditation awards to the DAP Committee
• other general duties
  
  • assist with the maintenance of facility profiles, key contact lists, etc., to ensure information is current, accurate and reliable
  • provide advice to internal and external clients
  • assist with the continuous development and maintenance of accreditation methodologies 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 including training and orientation of assessors
  • 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

• identify best practices, opportunities for improvement, and follow-up actions required to address identified nonconformances
• make recommendations for accreditation awards to the responsible accreditation programs committee

Accountability

• inform the manager, laboratory medicine of any quality, safety or other risk issues related to accreditation assessment activities and ensure that any potential hazards and risks to patients and/or staff are recognized and minimized
• evaluate the activities of diagnostic facilities
• understand and respond to the requirements of facilities as they relate to the accreditation requirements
• participate in the improvement activities for quality and safety processes provided through the accreditation programs quality improvement program
• follow the policies and procedures of the College of Physicians and Surgeons of BC
• provide timely reports to the manager, laboratory medicine when requested

Skills and qualifications

Required skills and qualifications include:

• graduation from a recognized program in medical laboratory technology
• Canadian Society of Medical Laboratory Science (CSMLS) certification
• graduation from a recognized post-secondary institution in a health-related discipline and/or five years’ 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
• evaluation and critical thinking 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

The compensation range for this position is $87,392 to $109,240 per year. 

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.

We thank all applicants for their interest; however, only those selected for interview will be contacted.

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.