College of Physicians and Surgeons of British Columbia

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DIAGNOSTIC ACCREDITATION PROGRAM College of Physicians and Surgeons of British Columbia 300 669 Howe Street Telephone: 604-733-7758 Vancouver BC V6C 0B4 Toll Free: 1-800-461-3008 (in BC) www.dap.

1 DIAGNOSTIC ACCREDITATION PROGRAM College of Physicians and Surgeons of British Columbia Howe Street Telephone: Vancouver BC V6C 0B4 Toll Free: (in BC) Fax: The Diagnostic Accreditation Program (DAP) has an immediate vacancy for a part time (0.8FTE) Diagnostic Imaging, Accreditation Assessment Officer. This position has responsibility for assessing the performance of the diagnostic imaging facilities/services of British Columbia for the purposes of awarding accreditation. This unique position offers a reduced work week, travel opportunities and a chance to drive quality improvement in diagnostic imaging services within British Columbia. As a program of the College of Physicians and Surgeons of BC (College), the DAP has a mandate to assess the quality of diagnostic services in the province of British Columbia. The DAP is committed to promoting excellence in diagnostic health care by establishing performance standards and conducting accreditation assessment activities to ensure the delivery of safe, high quality diagnostic service. The College has been recognized as one of British Columbia s top employers for the third year in a row. The College is centrally located in downtown Vancouver in a modern premise which is one block from a Skytrain station. In addition to an excellent working environment and organizational culture, the College can offer a highly competitive remuneration package and a comprehensive, 100% employer paid, benefits plan which includes a choice of two retirement planning options. As an employer we are committed to employee development and offer opportunities for personal and professional growth. Our goal is to attract, develop and retain highly talented employees and if you would like to join us please review the full job description and submit your resume and cover letter by February 1, 2013 to: hr@cpsbc.ca Attention: Recruiter, Human Resources For further information about the Diagnostic Accreditation Program please visit: We thank all those who apply, however, only candidates selected for an interview will be contacted. Enhancing public safety through excellence in diagnostic medicine accreditation

2 POSITION DESCRIPTION Accreditation Assessment Officer, Diagnostic Imaging, Diagnostic Accreditation Program (part-time 0.8 FTE) Work Hours Reports to 8:30 a.m. 4:30 p.m. Monday Thursday Manager, Accreditation Services Posting Date Department Accreditation Services POSITION SUMMARY The College of Physicians and Surgeons of British Columbia (CPSBC) protects the public by establishing and endorsing high standards of medical practice by licensed physicians. The Diagnostic Accreditation Program (DAP) is a program of the CPSBC and assesses the quality of diagnostic services in the province of British Columbia through accreditation activities. The DAP performs a regulatory function by establishing performance standards for diagnostic services and by accrediting and monitoring facilities against those standards. Reporting to the manager accreditation services, the accreditation assessment officer (AAO), diagnostic imaging, has responsibility for assessing the performance of the diagnostic imaging facilities/services of British Columbia for the purposes of awarding accreditation. Through conducting on-site assessments and reviewing evidence submissions of the diagnostic imaging 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 award provisional accreditation in accordance with policy set by the DAP committee; to review and sign-off on evidence submitted in response to outstanding mandatory requirements, and to make recommendations for accreditation awards to the committee. DUTIES AND RESPONSIBILITIES Duties include but are not limited to the following: Assessing the performance of the diagnostic imaging facilities services of British Columbia for the purposes of awarding accreditation: o Evaluates the diagnostic imaging facility s/service s level of actual performance to achieving the DAP accreditation standards. 2

3 o Reviews and evaluates desk top audit submissions. o Conducts on-site visits to the diagnostic imaging facility/service. Performs pre-assessment activities: o Answers queries from diagnostic imaging facilities/services related to the interpretation and the application of DAP accreditation standards. o Assists in the development of an accreditation strategy and schedule for each diagnostic imaging facility/service including reference to any regional/corporate structure models. Performs on-site assessments: o Reviews and evaluates evidence submissions from diagnostic imaging facilities/services in accordance with DAP assessment policies and procedures. o Conducts on-site assessments in accordance with DAP assessment policies and procedures. o Follows up with diagnostic imaging facilities/services, as required, for further information or clarification of submitted information. o Provides education and shares best practices for the purposes of assisting the diagnostic imaging facility/service to continually improve safety and quality. Performs post assessment activities: o Prepares reports resulting from the evaluation of evidence submissions and onsite assessments. o Identifies outstanding mandatory requirements to be addressed by the diagnostic imaging facility/service with associated timeframes for completion. o Performs the technical quality review of the report for the other diagnostic imaging, accreditation assessment officer. o Submits reports to the manager, accreditation services within the timeframe defined in the DAP service standards. o Makes recommendation to the DAP committee on the appropriate level of accreditation award for the diagnostic imaging facility/service assessed. Performs the activities of an accreditation officer: o Conducts initial assessments of new diagnostic imaging facilities/services; prepares initial assessment reports; and awards provisional accreditation in accordance with DAP committee policy. o Conducts focused visits as required and develops focused visit reports documenting findings from the focused visit and any recommended courses of action. o Reviews submissions from diagnostic imaging facilities/services in response to outstanding mandatory requirements and determines whether the diagnostic imaging facility/service has fulfilled the outstanding mandatory requirement. 3

4 o Follows-up directly with the facility as required to clarify information or ask for additional information. o Documents their assessment of fulfilling the outstanding mandatory requirement, or a recommended course of action to be taken by the diagnostic imaging facility/service. o Communicates and works effectively with the manager, accreditation services and accreditation specialist as it relates to these assigned duties. o Provides reports and documentation in a timely and prescribed manner to the manager, accreditation services. Other general duties: o Assists with the maintenance of facility profiles, key contact lists, etc. to ensure information is current, accurate and reliable. o Participates in the summation of significant findings and recommendations by geographic region overall; by size and type of organization; and by accreditation program. o Assists in the continuous development and maintenance of accreditation methodologies, standards, processes and tools. o Participates in communication and representation activities. o Facilitates meetings, forums, focus groups and workshops. o Contributes to the development and maintenance of educational programs. o Delivers educational programs assigned. o Attends meetings and functions at the direction of the manager, accreditation services. o Performs related duties as assigned. DECISION MAKING Identifies best practices, opportunities for improvement, and follow-up actions required to address outstanding mandatory requirements. Delegated authority to award provisional accreditation in accordance with policy set by the DAP committee. Makes recommendations for accreditation awards to the DAP committee. 4

5 ACCOUNTABILITY Informs the manager, accreditation services of any quality, safety or other risk issues related to accreditation assessment activities. 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 diagnostic facilities as they relate to the DAP. Participates in the improvement activities for quality and safety processes provided through the DAP quality improvement program. Follows the policies and procedures of the DAP and the CPSBC. Provides timely reports to the manager, accreditation services when requested. FINANCIAL AND RESOURCE MANAGEMENT This position is not responsible for finance or budget. SUPERVISORY RESPONSIBILITY This position does not have any supervisory responsibilities. SKILLS AND QUALIFICATIONS Required skills and qualifications include: Graduation from a recognized post-secondary institution in a health related discipline and/or 5 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 PROFESSIONAL CERTIFICATION, REGISTRATION OR LICENSURE Registered Technologist Radiology, Technology (RTR), Registered Technologist, Magnetic Resonance (RTMR), or Registered Technologist, Nuclear Medicine (RTNM) certification from the Canadian Association of Medical Radiation Technologists (CAMRT); or Canadian Registered Cardiac Sonographer (CRCS) or Canadian Registered General Sonographer (CRGS) certification from the Canadian Association of Registered Diagnostic Ultrasound Professionals (CARDUP); or Registered Diagnostic Medical Sonographer (RDMS) certification from the American Registry for Diagnostic Medical Sonography (ARDMS). 5

6 SKILLS AND ABILITIES 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 license Ability and willingness to drive The College of Physicians and Surgeons of British Columbia is recognized as one of BC s Top Employers for the second year in a row. 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. If you would like to join us, please send a cover letter, along with your resume to: hr@cpsbc.ca Attention: Recruiter, Human Resources We thank all those who apply, however, only candidates selected for an interview will be contacted. 6

DIAGNOSTIC ACCREDITATION PROGRAM. Accreditation Process

DIAGNOSTIC ACCREDITATION PROGRAM Table of Contents Introduction... 1 Initial Assessment Process... 2 Spirometry Initial Accreditation... 3 Relocation Assessment Process... 5 Ongoing Accreditation... 6