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Position Summary
With direction from the Assistant Registrar, the Director, Accreditation works with the program managers to provide oversight, management, and delivery on all aspects of the Accreditation program. The Director is accountable and responsible for the design and development of appropriate plans, change management strategies, activities, and tools to ensure effective continuous quality improvement and ongoing evolution of the Accreditation program. The Director will also provide operational support to the Medical Facility Accreditation Committee (MFAC) and the accreditation expert panel.
Responsibilities
Provide oversight, management and execution on departmental objectives:
- Develop and maintain an effective organizational structure and collaboration with CPSA departments, accredited sites and stakeholders that supports the achievement of the operational and public safety goals of the program.
- Oversee and provide leadership for the integration and standardization of the Accreditation program components related to the diagnostic imaging, laboratory medicine, radiation safety, pulmonary function diagnostics, Cardiac Stress Testing, sleep medicine diagnostics, neurodiagnostics, psychedelic assisted psychotherapy, and non-hospital surgical facilities components through standards and assessment research, development, testing and evaluation.
- Develop a surveyor recruitment, development and evaluation strategy to support in conducting assessments according to written program policies, procedures, processes and protocols.
- Oversee and continuously develop the management of facility information, planning of surveys, generation of accreditation and management reports and analyzing results.
- Monitor the performance of facilities and services through the establishment of a robust quality indicator program.
- Liaise with external partners including Hospital and Surgical Health Services (HSHS), Acute Care Alberta (ACA) and the Western Canadian Accreditation Alliance (WCAA)to ensure the ongoing relevance and effectiveness of the accreditation program within Alberta’s health system.
- Develop and maintain the decision-making process and procedure mechanisms to support the Medical Facility Accreditation Committee and accreditation expert panel.
Develop and execute on the department’s organizational strategy:
- Work closely with department staff and other operational departments including Communications, Information Management and Corporate Services to develop and maintain a strategic marketing, communications and financial plans for the accreditation program based on changes within marketplace.
- Work collaboratively with the People and Culture team on any people management strategies and changes.
- Develop strategies to apply input from key stakeholders regarding the quality of programs and services, learning needs and the program’s relevance.
- Develop collaborative relationships with external partners, including with AMA, other regulatory bodies, and other medical regulators across Canada. This work includes supporting the Federation of Medical Regulatory Authorities of Canada special Interest Group (FMRAC SIG) for accreditation.
Work with the Assistant Registrar to provide leadership and direction within the department:
- Financial oversight of the departmental budget including business planning, forecasting and aligning resources to strategic priorities.
- Onboard, support and develop department staff; while applying performance management and retention strategies where appropriate.
- Maintain a climate that attracts, retains, and motivates staff in order to enable high levels of performance and engagement within the department.
- Oversee and provide leadership for the planning and development of policies to provide guidance and framework for the integration and standardization of the programs.
- Conduct performance evaluations for direct reports and oversee performance management of department staff overall.
- Monitor and report to the Assistant Registrar on KPI’s, risks, personnel and financial objectives.
- Develop short and long-term operational plans and budgets for the Accreditation department.
- Oversee departmental activities, monitor progress and evaluate progress, including financial management.
- Keep informed of developments in accreditation, quality improvement, public safety and regulatory management to help the department operate with initiative and innovation.
Other duties as required
Preferred Qualifications and Experience
- Bachelor’s degree, preferably in a healthcare related field
- 10 years of related experience, including 5 years of progressive and/or senior leadership experience
Preferred Qualifications and Experience
- Experience leading larger teams of 10+ people; with a proven ability to, mentor, motivate and develop team members.
- Knowledge of the HPA and other relevant legislation and standards.
- Proven ability to lead financial planning, budgeting and resource allocation.
- Excellent organization, planning and prioritization skills, with the ability to manage multiple demands and achieve results.
- Exceptional communication skills; superior analytical reasoning and systems-level thinking with the ability to interpret and evaluate complex information while identifying patterns and essential issues.
- Ability to use initiative and take appropriate action proactively and when unforeseen circumstances arise.
Role Competencies
- Collaboration – Working with other team members and partners to achieve objectives and share solutions while respecting and valuing the contributions of all team members.
- Integrity – Incorporating CPSA’s values in all business interactions, decision making and actions while acting in an honest, consistent and ethical way.
- Informed Communication – Communicating in a way that is appropriate and respectful while ensuring clarity and accuracy.
- Adaptability – Remain open and willing to adapt our business processes, environment and operations while maintaining effectiveness.
- Critical Thinking / CQI – Applying an objective analysis and evaluation to problems using evidence, knowledge, experience and best practice, with the goal of continuous quality improvement to process, outcomes and operations.
- Customer Experience Focused – Building strong relationships with internal and external customers while striving to anticipate customer needs.
- Coaching / Developing Others – Providing open, honest and courageous feedback to team members to develop their skills, abilities and goals.
- Managing Change – Facilitating and implementing organizational change in a structured and deliberate manner while managing the expectations and change experience for team members.
- Modeling and Managing Accountability – Acceptance of personal and team accountability while holding team members accountable to their own contributions and performance.
- Strategic Focus – Setting organizational goals and objectives that align with the vision, mission and values of CPSA while articulating those objectives in a clear, concise and consistent manner across the organization.
- Driving Change and Innovation – Staying current with industry trends and finding alignment with CPSA’s strategic plan to be agile, innovative and relevant. Setting expectations and appropriately managing
organizational change with the executive leadership team.
