Accreditation Assessment Officer, Laboratory

7 months ago

Vancouver, Canada CPSBC Careers Full time

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.
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
- 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 form 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
- perform related duties as assigned

Decision-making
- identify best practices, opportunities for improvement, a

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