CPSO’s Quality Improvement (QI) Program for individual physicians builds on the principles of right-touch regulation and our commitment to fulfill our mandate ensuring quality care for patients in Ontario.

The QI Program is proactive, self-directed and encourages physicians to reflect on their own delivery of health care without a large time commitment.

To access the program, physicians will log on to CPSO’s online platform, where they will find easy-to-use learning modules designed to provide them with practical ways to continuously assess and improve their practices.

The Quality Improvement (QI) Program for Individuals and its Groups subset are comprised of multiple learning activities wherein participating physicians can earn up to 34 CPD credits. Here is an overview of each:

The QI Survey is a questionnaire that provides the College with current information about a participant’s clinical setting. The information disclosed is used by QI Program staff to better understand a physician’s practice and may be used in combination with the Practice Improvement Plan to assist in implementing ongoing QI.

The Practice Profile is an independent self-assessment designed to educate physicians about the evidence-based risk and support factors that could impact their practice. The Practice Profile’s aim is to provide resources to enhance positive practice.

The Self-Guided Chart Review allows physicians to engage in self-guided learning to enhance their compliance with CPSO’s Medical Records Documentation policy. This self-directed chart review engages physicians in both reflection and conversation with a trusted peer when developing a Practice Improvement Plan.

Data-Driven Quality Improvement is designed to get physicians looking at their own practice-level data to reflect on how they deliver health care to their patients and to identify opportunities for improvement.

The Practice Improvement Plan is to be completed by physicians in the Individual stream. In their Practice Improvement Plans, physicians identify areas of strength and areas for improvement in their practice, and develop a minimum of two goals. After the completion of this activity, the Practice Improvement Plan will be reviewed by a physician QI coach.

Coaching will be available when needed. QI coaches will offer participants support to further develop and refine their Individual or Group Practice Improvement Plans.

For the Practice Improvement Plan, some examples of real-life improvement ideas include:

Clinical goals:

• Children are overdue for 18-month immunizations: Identify target population of children less than two years of age to determine how many are up to date with their 18-month immunizations; develop interventions to address the gap; remeasure after six months.
• Pacemaker patients have not received required follow-up during COVID: Improve follow-up of pacemaker patients by defining the target population, developing communication strategies and assessing outcomes (number of patients who received appropriate and timely follow-up).
• Implement patient satisfaction surveys to capture the patient experience.
• Increase use of secure eForms from 9 to 25 per week and re-evaluate quarterly.
• Prescribe nature to target population at least once a week per provider, using an evidence-based online nature prescription tool embedded in the Group’s EMR; after three months, measure number of prescriptions per provider.

Wellness goal:

• Enroll and participate in an evidence-based course on the topic of managing secondary traumatic stress, self-compassion, and/or mindfulness; develop SMART goals, based on course content and recommendations, to enhance physician wellness.

• Transcript for QI for Individuals Model infographic

  Image 1:

  The QI Program is a 5-year cycle.

  Physicians will first engage with Quality Improvement Modules including the Practice Profile, Self-Guided Chart Review (which includes peer review) and a Data Driven QI.

  Following the completion of those modules they will create a practice Improvement Plan which identifies a physician’s strengths and sets two SMART goals for improvement.

  CPSO’s QI Coaches will review the Practice Improvement Plan.

  Image 2:

  If the Practice Improvement Plan meets all requirements it will be approved, and a physician will successfully complete the QI Program.

  If additional support is needed a physician may be referred to coaching, after which they either complete the program with coaching support or are referred to QAC or another CPSO program.