Independent Health Facilities

Quality Assessment

The College conducts quality assurance assessments of all Independent Health Facilities (IHFs). IHFs are licensed by the Ministry of Health and Long-Term Care and provide OHIP insured services, including services such as:

In diagnostic facilities: radiology; ultrasound; magnetic resonance imaging; computed tomography; nuclear medicine; pulmonary function studies; and sleep medicine.

In treatment or surgical facilities: one or more of a variety of procedures in peripheral vascular disease; plastic surgery; obstetrics/gynaecology; dermatology; nephrology; ophthalmology; and endoscopy.

How is a facility chosen for assessment?

The Director of the Independent Health Facilities program at the Ministry of Health and Long-Term Care (the “Ministry”) may request the College to perform an assessment “where the Director consider[s] it necessary or advisable.”

On an annual basis, the Ministry selects facilities to be assessed by the College. It is the mandate of the Ministry to ask the College to assess every IHF in Ontario on an ongoing basis, at least once during each facility’s three-five year licensing period.

The assessment of each facility is based on adherence to guidelines, called clinical practice parameters and facility standards, which have been developed for services offered in an IHF. In the absence of specific guidelines, adherence to the current generally accepted medical standard of practice is assessed.

Who conducts the assessment?

The College’s IHF staff selects an assessment team. The team is composed of a specialty-specific peer physician, and a technologist or nurse depending on whether the assessment is of a diagnostic and/or an ambulatory/surgical facility.

The College’s IHF staff notifies the facility that the Ministry has requested the assessment and asks that the facility arrange with the assessment team a mutually convenient time for the assessment to occur. A pre-visit questionnaire is also sent to the facility to complete and return to the assessor prior to the assessment.

The assessment team meets with the facility’s owner/operator, quality advisor and other relevant staff members, and the following information is available for review:

  • Quality advisor’s agreement with the facility;
  • Policies and procedures manual;
  • Preventive maintenance, and equipment and supply records;
  • Staff qualifications and appropriate attendance at CME activities;
  • Patient procedures being performed for which the facility is licensed;
  • Patient requisitions, films/charts and reports;
  • Requesting and reporting mechanisms for diagnostic procedures; and
  • Quality management activities.

Note:

  1. The assessors may request copies of some documentation to take with them.
  2. The Ministry may ask the College to conduct quality assessments and inspections on IHFs without advance notice where there is a follow-up assessment/inspection or an assessment arising from a complaint.

What happens after the on-site assessment is completed?

The assessment team prepares a report outlining all findings and submits it to the College. This report specifies whether the facility is meeting or is in breach of the clinical practice parameters and facility standards or current standards of practice. Where a facility is in breach of current standards, the report will also indicate how the facility can improve to meet the clinical practice parameters and facility standards for that specialty.

For diagnostic imaging facilities, where the report suggests a significant breach of the parameters and standards, the College will convene a Facility Review Panel (FRP) to provide advice to the College on the aspects of concern and whether licensing action may be required.

For sleep medicine and pulmonary function facilities, due to the complexity and technical nature of these services, all assessment reports are reviewed by a Facility Review Panel (FRP) to provide advice to the College on whether the IHF is meeting the current parameters and standards.

The College Registrar sends the assessment report, FRP findings (where applicable) to the IHF Director. The IHF Director sends the assessment report, FRP findings (where applicable), and Ministry recommendations to the facility for response. Failure to comply with the IHF Director’s request to provide a response to the recommendations could result in further action by the Director, IHF. The College is charged with the task of ensuring that the facility satisfactorily addresses all the recommendations within the assessment report, and notifying the IHF Director of the facility’s compliance.

Questions?

Contact the College: 416-967-2600 ext. 223 or 776