Accreditation Assessment Officer (Registered Nurse), Accreditation Program

Full-time, permanent

We are looking for a nurse with specialized training in perioperative nursing, peri anesthesia or critical care nursing to join the College of Physicians and Surgeons of BC in the accreditation department as an accreditation assessment officer. This is an exciting opportunity to impact healthcare quality in BC.

Reporting to the manager, accreditation services, non-hospital medical and surgical facilities accreditation program (NHMSFAP), the accreditation assessment officer is responsible for assessing the performance of facilities for the purpose of awarding accreditation.

Through accreditation assessments and review of evidence submissions from facilities, the accreditation assessment officer writes reports identifying nonconformances, opportunities for improvement, and follow-up actions required to address nonconformances.

The accreditation assessment officer reviews evidence submitted by facilities in response to nonconformances and based on those findings makes recommendations on the term of accreditation for the NHMSFAP Committee’s consideration.

Duties and responsibilities

Duties include but are not limited to the following:

• assess the performance of facilities for the purpose of awarding accreditation
  • evaluate facilities using the NHMSFAP accreditation standards
  • review and evaluate facilities’ evidence submissions
  • conduct accreditation assessments
• perform pre-assessment activities
  • collaborate with program staff to determine pre-accreditation evidence needed in advance of on-site assessment
  • assist program staff in answering queries from facilities related to the interpretation and the application of accreditation standards
  • assist with the development of an accreditation strategy
• perform accreditation assessments
  • conduct accreditation assessments in accordance with NHMSFAP assessment policies and procedures
• perform post-assessment activities
  • prepare reports resulting from facility evidence submissions and accreditation assessments
  • identify requirements to be addressed by the facility with associated time frames for completion
  • review reports with the manager, accreditations as required
• perform the activities of an accreditation assessment officer
  • participate in and/or lead the accreditation team throughout the accreditation assessment
  • assist with initial assessments of new facilities/services and the preparation of the assessment reports
  • conduct focused assessments as required and prepare focused assessment reports documenting nonconformances and requirements
  • review submissions from facilities in response to nonconformances and determine whether the facility has fulfilled the requirements
  • follow up directly with the facility as required to clarify or ask for additional information
  • document facility fulfillment of requirements and/or recommend course of action to be taken by the facility
  • communicate and work effectively with the manager, accreditations as it relates to these assigned duties
  • provide reports and documentation in a timely and prescribed manner to the facility
• other general duties
  • assist with the continuous development and maintenance of accreditation methodologies and standards
  • assist with the development of accreditation processes, procedures and tools
  • discuss accreditation requirements and present recommendations to the manager, accreditations
  • attend meetings and functions at the direction of the manager, accreditations, the director and the deputy registrar
  • assist with assessor recruitment
  • assist with onboarding and orientation of new assessors
  • perform related duties as assigned
• identify best practices, opportunities for improvement, and follow-up actions required to address nonconformances
• make recommendations for accreditation awards to the NHMSFAP Committee
• inform the manager, accreditation services NHMSFAP, 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 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 (CPSBC)
• provide timely reports to the manager, accreditation services when requested

Skills and qualifications

Required skills and qualifications include:

• current practising registration with the British Columbia College of Nurses and Midwives (BCCNM)
  • specialty training in perioperative nursing and/or perianesthesia or critical care nursing
  • five years of recent related clinical experience in perioperative and/or perianesthesia or critical care nursing
  • current Canadian Nurses Association specialty certification an asset
  • professional certification in infection prevention and control an asset
  • experience working with accreditation programs an asset
  • evaluation and critical thinking skills
  • exceptional client service skills
  • facilitation of large groups
  • excellent communication skills, both written and oral
  • strong writing and editorial skills to write reports
  • professional and business-like manner
  • possession of a valid BC driver’s licence
  • ability and willingness to travel

The compensation range for this position is $83,425 to $125,137 per year. The compensation range is the span between the minimum and maximum base salary for a position. The midpoint of the range is approximately halfway between the minimum and the maximum and represents an employee that possesses full job knowledge, qualifications and experience for the position. In the normal course, employees will be hired, transferred or promoted between the minimum and midpoint of the salary range for a job. 

In addition to the base salary, the College provides pension contributions to the public service pension plan, a parking/transit subsidy, a wellness allowance, and a flexible health and dental plan as part of the total compensation package.

The College offers other great benefits such as flexible working arrangements (compressed work week, hybrid work-from-home/in-office model), competitive annual vacation and personal days off, support for professional development, coverage for BCCNM registration,  and access to a fitness centre and pool, all of which make the College an excellent and rewarding working environment.