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College of Physicians and Surgeons of BC
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Accreditation Assessment Officer, Laboratory Medicine

Reference ID: CPSBC171

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Job Location icon
Vancouver, BC
Job Type icon
Full Time
Job Category icon
Health Care
Quality Assurance


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 and reviewing evidence submissions 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 outstanding mandatory requirements. 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 outstanding mandatory requirements, and to make recommendations for accreditation awards to the Diagnostic Accreditation Program (DAP) Committee.

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 evaluation of evidence submissions and on-site assessments
    • identify outstanding mandatory requirements 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 visit reports documenting findings from the focused visit and any recommended courses of action
    • review submissions from laboratory medicine facilities/services in response to outstanding mandatory requirements and determine whether the laboratory medicine facility/service has fulfilled the outstanding mandatory requirement
    • follow up directly with the facility as required to clarify information or ask for additional information
    • document the assessment of fulfilling the outstanding mandatory requirement, 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
    • participate in the summation of significant findings and recommendations by geographic region overall, by size and type of organization, and by accreditation program
    • assist in the continuous development and maintenance of accreditation methodologies, standards, 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
    • perform related duties as assigned
  • identify best practices, opportunities for improvement, and follow-up actions required to address outstanding mandatory requirements
  • make recommendations for accreditation awards to the DAP Committee
  • 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 diagnostic facilities as they relate to the DAP
  • participate in the improvement activities for quality and safety processes provided through the DAP quality improvement program
  • follow the policies and procedures of the DAP and the College
  • provide timely reports to the manager, laboratory medicine when requested

Decision-making Accountability

Skills and qualifications

Required skills and qualifications include:

  • medical laboratory technologist with RT 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’ 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 College of Physicians and Surgeons of British Columbia has been recognized as one of BC’s top employers since 2011 and one of Canada’s top 100 employers since 2014. Our goal is to attract, develop and retain highly talented employees. We offer an excellent working environment, opportunities for personal and professional growth, and a comprehensive benefits package.

All applications for this position must be submitted online at https://www.cpsbc.ca/about-us/careers.

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


Posted: May 7, 2018
Closes: July 6, 2018
Email Address:
Company Info
Size:
51-200 employees
Industry:
Health Care
Public Administration

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About College of Physicians and Surgeons of BC

The College of Physicians and Surgeons of British Columbia regulates the practice of medicine under the authority of provincial law. All physicians who practise medicine in the province must be reg...