Accreditation Assistant, Non-Hospital Medical and Surgical Facilities Accreditation Program (12-month contract)

Job No: CPSBC431
Location: Vancouver, BC


Reporting to the quality improvement lead, Non-Hospital Medical and Surgical Facilities Accreditation Program (NHMSFAP), the accreditation assistant will work collaboratively with program staff and other College departments to uphold its mandate to establish, monitor and ensure standards of practice in private medical and surgical facilities in British Columbia.

This position is varied and complex, and the incumbent is expected to act professionally, demonstrate initiative, exhibit good judgment, and make informed decisions. This position interacts regularly with the deputy registrar, director, NHMSFAP staff, other College departments, and external stakeholders.


Duties include but are not limited to the following:


  • work independently and collaboratively with other program staff to ensure the department functions efficiently and effectively
  • prepare correspondence and meeting agendas, record, transcribe, edit, and distribute minutes for the program, prepare briefing notes, meeting package, board reports and draft and send panel follow-up letters for NHMSFAP panel meeting
  • coordinate and schedule appointments, conferences, meetings, and special events for internal and external stakeholders
  • prepare written communication pertaining to a variety of NHMSFAP matters
  • review credentialing and privileging applications, follow up with the non-hospital facility for pending documents, prepare and send privileging letter, update database and post payment in the registrant portal
  • prepare patient safety incident summary and compile the incident report, follow up with the non-hospital facility
  • manage and contribute to the ongoing improvement of the NHMSFAP database and other program-related IT initiatives
  • manage electronic files on SharePoint system and paper files in compliance with the College records retention policies
  • track key performance indicators for program activities
  • support the continuous improvement of the NHMSFAP by participating in internal audits, nonconformance management, document and records management, and other elements of the quality management system
  • respond to inquiries from College staff, the public, non-hospital medical/surgical facilities and other offices external to the College on a wide range of topics
  • manage annual facilities statistical reporting process to facilitate oversight of facility activities and invoicing of annual fees
  • prepare annual fee statements in collaboration with the finance department
  • develop administrative processes, policies and procedures related to the NHMSFAP
  • perform other duties as assigned

NHMSFAP Committee

  • assist with all aspects of the NHMSFAP Committee and the Patient Safety Incident Review Panel meetings and other meetings as they may arise as follows:
    • schedule meeting dates and book resources as necessary
    • prepare agenda, summaries, compile and distribute meeting packages
    • compose, edit and distribute minutes
    • prepare correspondence in response to action items arising on behalf of deputy registrar, chair(s), director, and quality improvement lead

Medical staff credentialing and privileging 

  • conduct preliminary assessments of applications for medical staff appointment at non-hospital facilities ensuring that the medical director has submitted all the applicant’s relevant information including credentials, training and current experience
  • conduct preliminary assessments of applications for Diagnostic Accreditation Program restricted services applications
  • analyze the applicant/registrant’s credentials with the Royal College of Physicians and Surgeons of Canada specialty, subspecialty, special program, and/or diploma requirements
  • analyze the applicant/registrant’s credentials with requirements set out by the provincial or federal authorities related to that area of practice (e.g. dentistry)
  • analyze the applicant/registrant’s credentials and current experience with requirements outlined in the BC Medical Quality Initiative provincial dictionaries
  • follow up with facilities to provide supporting documentation or additional information, including information about credentials, training and current experience
  • review the applicant/registrant’s registration history with other College departments and medical regulatory authorities (i.e. monitoring, complaints, disciplinary or other issues)
  • respond to applicant/registrant and facility inquiries
  • prepare NHMSFAP Committee summaries
  • manage posting of payments for credentialing and privileging activities

Patient safety incident review

  • maintain the tracking system to record preliminary reporting and ensure all patient safety incident reports are received in a timely manner and include all required documentation
  • conduct preliminary investigation through collection of necessary information for the analysis of patient safety incidents (e.g. health record, timeline of events, relevant policies and procedures, accreditation standards, other evidence-based guidelines, etc.)
  • prepare summaries of patient safety incident reports for program and panel review
  • coordinate review of patient safety incident reports by external experts
  • prepare patient safety incident analysis summaries for the NHMSFAP Patient Safety Incident Review Panel
  • prepare and send panel post-meeting correspondence
  • ensure follow-up items from the panel meetings are completed


Required skills and qualifications include:

  • post-secondary education with training in administrative practices or an equivalent combination of education and experience
  • a minimum of three years of related experience is required
  • ability to work both independently and as a team member
  • interpersonal and organizational skills, excellent oral and written communication with accuracy and attention to detail
  • ability to demonstrate a high level of initiative, analytical and investigative skills ability to multi-task, prioritize, work under pressure and meet deadlines
  • ability to interpret, research and apply complex standards and processes
  • ability to exercise good judgment in recognizing scope of authority and protecting confidential information
  • ability to type 70 wpm and operate a normal range of office equipment
  • intermediate knowledge level of MS Office software that includes word processing, spreadsheet, database applications, PowerPoint, electronic mail and scheduling applications
  • excellent editing and proofreading skills
  • experience in medical/surgical office administration an asset
  • previous experience interfacing with patients or the public is an asset

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 including a hybrid work-from-home/in-office model, opportunities for personal and professional growth, and a comprehensive benefits package.

Click here to download the position description.

How To Apply

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.

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.

The College welcomes all applicants and is dedicated to promoting a diverse, equitable and inclusive environment.



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College of Physicians and Surgeons of British Columbia