Accreditation Assessment Officer, Non-Hospital Medical and Surgical Facilities Accreditation Program

Job No: CPSBC245
Location: Vancouver, BC


Reporting to the manager, accreditations, 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 on-site assessments and review of evidence submissions from facilities, the accreditation assessment officer writes reports identifying evidence-based best practices, opportunities for improvement, and follow-up actions required to address outstanding requirements.

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


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 on-site facility 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 in the development of an accreditation strategy
  • perform on-site assessments
    • conduct on-site assessments in accordance with NHMSFAP assessment policies and procedures
  • perform post-assessment activities
    • prepare reports resulting from facility evidence submissions and on-site assessments
    • identify requirements to be addressed by the facility with associated time frames for completion
    • submit reports to the manager, accreditations within the defined time frame
    • assist the manager, accreditations in making recommendations on an appropriate term of accreditation for the facility assessed
  • perform the activities of an accreditation assessment officer
    • participate in and/or lead the accreditation team throughout the accreditation site visit
    • conduct initial assessments of new facilities/services and prepare initial assessment reports
    • conduct focused visits as required and develop focused visit reports documenting findings from visits and any recommended courses of action
    • review submissions from facilities in response to requirements 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 accreditation officer as it relates to these assigned duties
    • provide reports and documentation in a timely and prescribed manner to the manager, accreditations
  • other general duties
    • assist in the continuous development and maintenance of accreditation methodologies and standards
    • assist in 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
    • perform related duties as assigned


Required skills and qualifications include:

  • current practising registration with the College of Registered Nurses of British Columbia (CRNBC)
  • graduation from a recognized school of nursing with 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
  • current and ongoing commitment to maintaining perioperative and/or perianesthesia clinical practice in an acute hospital setting
  • 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

Click here to download the position description.

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 via this page.

Please read through all of the questions; you may wish to prepare your responses in a Word document before you start filling out the fields below.

To begin the application process, complete the questions below. You will have the opportunity to attach your resume and other documents on the next page. 

Note: You must submit your resume online. Ensure you have your resume ready to attach.

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


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