Out-of-Hospital Premises Inspection Program

Notice: In December 2017, the government passed Bill 160, the Strengthening Quality and Accountability Act. creating a single legislative framework for “community health facilities” which includes independent health facilities (IHFs) and out-of-hospital premises (OHPs). Details can be found in this January 3, 2018 communique from the Ministry of Health and Long-Term Care

Once the new legislation is proclaimed, the CPSO’s IHF and OHP programs will be governed by the new Oversight of Health Facilities Act, 2017, which brings new licensing and inspection requirements, and increases transparency regarding inspection outcomes. 

The CPSO is working with government to help establish the regulations under the Act and any program changes that will be needed. Until the Act is proclaimed, there will be no changes to IHF and OHP programs and facilities should continue to comply with existing IHF legislation and OHP regulations. Facilities will be kept up to date on the implementation of the new legislation and any new requirements.

OHPIP program standards cover imgUpdated OHPIP Program Standards

Revised October 2017

The OHPIP Standards document includes core requirements for the performance of procedures involving the use of anesthesia in settings/premises outside a hospital that do not fall under another regulatory oversight scheme.  

Looking for updated Independent Health Facilities (IHFs) guidelines? Visit our CPGs and Other Guidelines page

Premises required to report adverse events to College

A by-law that requires out-of-hospital premises to report adverse events to the College is now in place.

The by-law was circulated for feedback to the profession and was returned for decision at the May 2013 Council meeting.

The by-law is needed to create a two-tier framework for the reporting of adverse events. The by-law defines the types of Tier 1 adverse events which physicians must report to the College, within 24 hours of learning of the event. The Tier 2 adverse events reporting requirements will be outlined in the OHP Standards document, when it is updated. Tier 2 events did not form part of the external consultation.

Find out more and access reporting forms for physicians.

About the OHPIP Program

On April 9, 2010, an amendment to Regulation 114/94 under the Medicine Act adding Part XI, Inspection of Premises where Certain Procedures are Performed came into effect.

The Regulation applies to two groups of physicians:

  • Those who are already performing procedures in an out-of-hospital premises at the time the Regulation came into effect on April 9, 2010; and
  • Those who intend to perform procedures in the future.

If you intend to commence performing procedures at an out-of-hospital premises as defined in the Regulation, you are required to provide written notice to the College and you are not permitted to begin using these premises until the premises passes an inspection. We shall ensure that an inspection is conducted within 180 days from the day the College receives notification from you.

An online notification form is available to assist you in providing the required information.

Does this apply to you?

This new requirement applies to you if you perform, or plan to perform, any procedures in an out-of-hospital premises that, when performed in accordance with the accepted standard of practice, are performed under the administration of any of:

  • general anesthesia;
  • parenteral sedation (administered by intravenous, intramuscular or subcutaneous injection);
  • regional anesthesia (except for a digital nerve block);
  • a local anesthetic agent, including, but without being limited to,
  1. any tumescent procedure involving the administration of dilute, local anesthetic;
  2. surgical alteration or excision of any lesions or tissue performed for cosmetic purposes;
  3. injection or insertion of any permanent filler, autologous tissue, synthetic device, materials or substances for cosmetic purposes;
  4. a nerve block solely for the treatment or management of chronic pain; or
  5. any act that is similar in nature to those set out in subclauses (i) to (iii) and that is performed for a cosmetic purpose.

You are not required to complete the notification form if the only procedures you are performing in an out-of-hospital premises are any of the following:

  • surgical alteration or excision of lesions or tissue for a clinical purpose, including for the purpose of examination, treatment or diagnosis of disease;
  • minor dermatological procedures including, without being limited to, the removal of skin tags, benign moles and cysts, nevi, seborrheic keratoses, fibroepithelial polyps, hemangioma and neurofibromata;
  • Lasik surgeries; or
  • cosmetic procedures that do not involve general, regional or parenteral anesthesia including, without being limited to, temporary fillers, laser skin resurfacing, botox and sclerotherapy.


To view the complete Regulation, please see Part XI, Inspection of Premises where Certain Procedures are Performed of Regulation 114/94 under the Medicine Act on the government's e-laws website.