The Peer and Practice Assessment Process

What is reviewed during the assessment?

Medical Records

A detailed review of a physician’s medical record keeping system enables the assessor to develop a picture of the physician’s practice and an understanding of his/her approach to patient care.

Many of the components of the medical record that are considered during an assessment are required by regulation, while others have been shown to be extremely useful in facilitating the documentation of information that is necessary to quality patient care and are referenced in the College’s Medical Records policy. For example, family physicians must maintain a Cumulative Patient Profile (CPP) containing a brief summary of essential information in each patient’s family practice chart. While a CPP is highly recommended for specialists’ patient charts, especially those seeing patients on an ongoing basis, there may be variations in format based on specialty.

There are various best practices that are highly recommended by the College. The Subjective, Objective, Assessment and Plan format (SOAP), commonly used for documentation can assist the physician in ensuring that s/he has thoroughly reviewed a presenting problem and developed a management plan. Templates, such as flow sheets for documenting and monitoring blood sugar levels in diabetic patients or INRs in patients on anticoagulants, can alert physicians about the need to modify a patient’s medical care. Additional assessment tools, including those related to record keeping, can be found in the right sidebar.

Quality of Patient Care

While assessors can garner some insight into patient management through a careful review of patient records, the subsequent discussion between the assessor and the physician is invaluable in helping assessors gain an understanding of the “story of the patient.” Based on information gathered through these two components, the assessor evaluates the physician’s ability to take an adequate history, conduct an appropriate examination, order the necessary diagnostic tests, identify the appropriate course of action, and monitor the patient as necessary.

While the types of patients seen and the problems they present will vary among specialties, there are commonalities to good patient care. The Quality Assurance Committee (QAC) has determined patient care can be broken down into components based on the nature of the patient encounter and developed corresponding protocols: 

  • New presentations/acute condition management
  • Management of patients with ongoing/chronic conditions
  • Health maintenance
  • Psychosocial care
  • Continuity of care and referrals
  • New consultations and pre-operative management
  • Operative patient management and procedures
  • Post-operative management and follow-up
  • Practice assessment report – Anesthesiology
  • Practice assessment report – Hematology/Oncology
  • Practice assessment report – Pathology
  • Practice assessment report – Psychiatry/Psychotherapy
  • Practice assessment report – Long Term Care
  • Practice assessment report – Emergency Medicine Management

Preparing for the assessment 

We highly recommend you consider…

  • Conducting a self-assessment using the available assessment protocols, identify opportunities for improvement and begin making necessary changes to your practice. Assessors and the QAC acknowledge there is room for growth in every practice; addressing these areas in a proactive fashion demonstrates motivation, and an appreciation for improvement and continuous learning. Additionally, these changes can be reviewed during the assessment.
  • Keeping a flexible schedule while the assessor is reviewing your records, as you will need to be available to answer questions during the review and for a discussion with the assessor following its completion. 
  • Developing a personal plan for continuing professional development (CPD) (if you have not already done so), and sharing it as well as a list of your previous CPD activities with the assessor during your discussion. 
  • Familiarizing yourself with the CPD credits available through MAINPRO, MOC or MDPAC for participating in the CPSO’s assessment process. Please visit the applicable website for further information:

On the day of the assessment

Assessments usually take a half-day to a full-day to complete. The assessor will require access to your daybook (if applicable) so that s/he can randomly select patients you have recently seen. The assessor will review the medical records of the selected patients, and will require you to be available to answer questions and review files. Please speak with the assessor when preparing for the assessment to determine whether you should book patients during this time. In addition, please arrange for a suitable private location in which the assessor can review the records and, if necessary, provide staff support to ensure access to the EMR system.

Following the record review, the assessor will meet with you for approximately 30 to 60 minutes to discuss patient management and record-keeping. This is an opportunity for you to obtain feedback from the assessor and to discuss opportunities for practice improvement. Surveyed physicians have told us this is the most valuable part of the assessment.

The assessor will provide you with a Post-Assessment Questionnaire to complete and return to the College. While optional, all comments are reviewed by program staff, your assessor and may be shared with the QAC. Your feedback is valuable as it provides useful information about individual assessment experiences and helps us further improve the process.

Following the assessment

The assessor conducting your peer and practice assessment prepares a written report on the assessment and submits it to the College. In approximately 12 weeks, you will receive a copy of the assessment report and a decision letter outlining the findings of your assessment. 

Outcomes of a peer and practice assessment and/or reassessment

The majority of physicians who undergo a peer and practice assessment are found to have met the current standards of practice in Ontario. However, there are some who require changes to their practice to meet those standards.

Possible outcomes may include: 

  • Satisfactory: The majority of physicians who undergo a peer and practice assessment receive a satisfactory outcome, which implies the Committee is of the opinion the member’s knowledge, skill and judgment are satisfactory, and no further action is required.
  • Opportunity to address the Committee’s concerns: If, after considering the report and any other relevant material, the Committee is of the opinion that the member’s knowledge, skill and judgement are not satisfactory; the Committee may give the member an opportunity to address the Committee’s concerns by way of a written response or in-person. At this point in the process, it is in the member’s best interest to provide a detailed response addressing the Committee’s concerns as outlined in the decision letter.
  • Peer and practice reassessment: If the Committee has identified outstanding concerns following the member’s opportunity to address, it may require a peer and practice reassessment. This reassessment may include a records review or a more comprehensive evaluation of the member’s practice.
  • Notice of Intent to take action under the HPPC 80.2 (1): If the Committee has identified record keeping and/or patient care concerns, it may use its powers under the Schedule 2 of the RHPA. Before doing so, the member will be granted at least 14 days to make a written submission to the Committee.

Under this statute, the Committee may do one or more of the following.

  • Require the member to participate in a Specified Continuing Education or Remediation Programs (SCERP); and/or
  • Direct the Registrar to impose Terms, Conditions, or Limitations (TCL); and/or
  • Direct the Registrar to remove Terms, Conditions, or Limitations (TCL) if knowledge, skills and judgment are now satisfactory;
  • Direct the Registrar to disclose the name of the member and allegations to the Inquiries, Complaints and Reports Committee (ICRC) if the QAC is of the opinion the member may have committed an act of professional misconduct, may be incompetent or may be incapacitated.

In some circumstances, the Committee may invite the member to participate in a voluntary undertaking where the member agrees to complete identified remediation activities, restrict their practice, or, if the member intends to retire, to commit to an agreed upon time in which to do so. This is decided on a case-by-case basis.

The Committee aims to promote continuing quality improvement throughout the peer and practice assessment process. In some cases the QAC’s decision may include recommendations for self-directed learning to improve a physicians’ knowledge, such as enrolling in a record-keeping program to improve documentation.

Can the results of my assessment be used in another CPSO forum?

The legislation governing the Quality Assurance Program prohibits sharing information obtained during an assessment with any other College committee, including the ICRC, Discipline Committee, Premises Inspection Committee, and Fitness to Practise Committee, except in the following circumstances:

  • If the Committee believes a physician may have committed an act of professional misconduct, or may be incompetent or incapacitated, the physician’s name and the allegation (but not the assessment information) can be shared with the ICRC;
  • Details of a physician’s Change in Scope of Practice or Re-Entry to Practice assessment can be shared with other College committees;
  • Undertakings between a physician and the College can be shared with other College committees;
  • Assessments conducted by or with the assistance of the QAC for the purpose of informing decisions of the Registration Committee;
  • Information that suggests a physician knowingly gave false information to the QAC or to an assessor can be shared with another College committee.

Can a decision of the QAC be shared outside the College?

The College’s commitment to transparency in support of protecting the public means those Committee outcomes where the member is required to participate in a SCERP, or has terms, conditions or limitations imposed on his/her certificate of registration (by means of an Order or signed undertaking) will be posted on the Public Register. It should be noted that terms, conditions and limitations have always been available on the Register; however, SCERPS required by the QAC will be publically available on the Register for decisions made on or after June 1, 2016. A notation will be added to the Register when all elements of the SCERP are completed to the satisfaction of the Committee.

Similarly, a member who signs an undertaking with the College is agreeing to the contents of the undertaking being posted on the Register. Educational undertakings will be removed from the Register when the member has, to the College’s satisfaction, met all requirements. The member’s registration history will reflect the dates an undertaking was in effect.

Still, much of the information collected by or prepared for the QAC is private information that cannot be shared with the public or other College committees.

In light of privacy legislation, is the College still permitted to review patient records without patient consent?

Yes. Privacy legislation (Personal Health Information Protection Act, Quality of Care Information Protection Act, 2004, and Personal Information Protection and Electronic Documents Act) does not affect the College’s authority to conduct assessments. Physicians are not required to seek patient consent to share patient information with the College for the purposes of a quality assurance assessment. If an assessment involves observing the physician in practice, patient consent is required for the observation component. Any member appointed by the QAC to conduct an assessment is bound by confidentiality.

Are there costs associated with a peer and practice assessment/reassessment?

In accordance with the College’s fee policy, the initial assessment and first reassessment required by the QAC will be of no charge to the member; any subsequent reassessments and peer and practice reassessment (comprehensive) are subject to a fee. Please refer to our fees by-law for further information.