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Peer and Practice Assessment

Reduce your anxiety by learning more about what you can expect when selected for an assessment and how you can prepare in advance.

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Who are Peer Assessors?

Assessors are typically physicians supportive of and interested in quality assurance, who help the CPSO conduct assessments of its members. We carefully screen and train them to conduct assessments, and provide feedback that validates appropriate care and supports opportunities for practice improvement. Due to increasing practice specializations, it is not always possible to assign an assessor with the same specialty certification as the assessed physician. In such cases, we make every effort to ensure the closest possible match between the physician’s and assessor’s scopes of practice. For example, we may assign a dermatologist familiar with laser tattoo removal to assess a family physician performing laser tattoo removal, even though their specialties are different. 


The Peer and Practice Assessment Process


What we review during the assessment?

Quality of Patient Care

While assessors garner some insight into patient management through a careful review of patient records, their subsequent discussion with physicians 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.

What criteria do we use to assess Patient Care and Medical Records?

When assessing patient care, appropriate documentation and opportunities for improvement, assessors rely on: 

  • Criteria established by regulations and CPSO policies;
  • Relevant clinical practice guidelines and evidence-based best practices; and
  • Their own clinical experience and judgement.

Medical Records

Many of the medical record’s components are required by regulation, while the CPSO’s Medical Records Documentation and Medical Records Management policies detail those components considered extremely useful in facilitating quality patient care. For example, family physicians must maintain a Cumulative Patient Profile (CPP) containing a brief summary of essential information in each patient’s family practice record. While a CPP or an equivalent health care summary is encouraged, specialists must use their professional judgement to determine whether to include a CPP or an equivalent patient health summary in each patient medical record, considering a variety of factors, such as the nature of the physician-patient relationship, the nature of the care being provided, and whether the CPP or equivalent summary would reasonably contribute to quality care. The College highly recommends various best practices, such as the Subjective, Objective, Assessment and Plan (SOAP) format. Commonly used for documentation, SOAP helps physicians ensure they have 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.

The College highly recommends various best practices, such as the Subjective, Objective, Assessment and Plan format (SOAP). Commonly used for documentation, SOAP helps physicians ensure they have 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.


Preparing for the assessment

There is room for improvement in every practice, so we highly recommend you consider:

  1. Conducting a self-assessment using the available assessment tools;
  2. Identify opportunities for improvement;
  3. Begin making necessary changes to your practice before the assessment; and
  4. Report changes to the assessor during your assessment.

Medical specialties share many elements important for patient care and medical record keeping, but there are also specialty-specific elements and competencies for each medical discipline. Addressing these areas proactively demonstrates motivation and an appreciation for improvement and continuous learning. 

In addition:

  • Keep a flexible schedule while the assessor reviews your records, as you need to be available to answer questions and have a discussion with the assessor following the chart review.
  • Develop a personal plan for continuing professional development (CPD), if you have not already done so. Share it, as well as a list of your previous CPD activities, with the assessor during your discussion.
  • Familiarize 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. You should arrange for a suitable private location where the assessor can conduct the review and ensure staff support is available to assist with accessing the EMR system, if necessary.
    • If your office or hospital-based practice use an Electronic Medical Record (EMR) system, it is the responsibility of the subject physician to make arrangements ahead of time to ensure the assessor has temporary, read-only access to the system.
  • The assessor may require access to your daybook (if applicable) to randomly select patients. 
  • The assessor reviews the selected patients’ medical records, during which you need to be available to answer questions and review files. Please check with the assessor to see if you should book patients during this time. 
  • Following the record review, the assessor meets 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 often the most valuable part of the assessment.

Following the assessment

The assessor conducting your peer and practice assessment prepares a written report on the assessment and submits it to the CPSO within three weeks of the assessment. You will receive a copy of the assessment report and a decision letter outlining the findings of your assessment in approximately 10 weeks.


Outcomes of a peer and practice assessment and/or reassessment

We find the majority of physicians who undergo a peer and practice assessment meet the current standards of practice in Ontario. However, some require changes to their practice to meet those standards.

Possible outcomes may include:

  • Satisfactory: The majority of physicians receive a satisfactory outcome. This means the Quality Assurance Committee (QAC) is satisfied with the results of the assessment, and concludes no further action is required and/or suggests the physician complete self-directed learning.
  • Opportunity to address the QAC’s concerns: If, after considering the report, the Committee  identifies aspects of the physician’s practice requiring additional information, the Committee may give the physician an opportunity to address its concerns by:
    • Submitting a written response for the QAC’s review, which may include redacted patient chart samples to show improvements made since the peer assessment. The physician may also choose to speak to a CPSO Medical Advisor for assistance in preparing the submission.
    • Speaking to a CPSO Medical Advisor to gain a better understanding of the physician’s practice and areas where improvements may be warranted. In these instances, the Medical Advisor prepares a written summary of the conversation. The physician will have an opportunity to review and approve this summary prior to the QAC’s review.
  • Peer and practice reassessment: If the QAC concludes there are still areas that would benefit from further development after the physician addresses its concerns,, it may require a peer and practice reassessment. The reassessment will include a patient records review similar to the initial assessment, but with a focus on whether or not the concerns identified in the previous assessment were addressed.
  • Notice of Intent to take action under HPPC 80.2 (1): If the Committee identifies record keeping and/or patient care concerns, it may use its powers under Schedule 2 of the Regulated Health Professions Act. Before doing so, QAC grants the physician 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 physician 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 disclose the name of the physician and allegations to the Inquiries, Complaints and Reports Committee (ICRC) if the QAC believes the physician may have committed an act of professional misconduct, or may be incompetent or incapacitated. 

In some circumstances, the QAC may invite the physician to participate in a voluntary Undertaking where they agree 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 you use the results of my assessment in another CPSO forum? 

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

  • If the QAC believes a physician may have committed an act of professional misconduct, or may be incompetent or incapacitated, their 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 CPSO committees; 
  • Undertakings between a physician and the CPSO can be shared with other College committees; 
  • Assessments conducted by or with the assistance of the QA Program staff  to inform Registration Committee decisions; or 
  • Information that suggests a physician knowingly gave false information to the QAC or an assessor can be shared with another CPSO committee. 

Can you share a QAC decision outside the CPSO? 

Most of the information collected by or prepared for the QAC is confidential and cannot be shared with the public or other College committees. But in support of the CPSO’s commitment to protecting the public, we must post outcomes on the Public Register that:  

  • Require a physician to participate in a SCERP; or  
  • Impose TCLs on their certificate of registration (by means of an order or signed Undertaking). 

When a physician signs an Undertaking with the CPSO, they agree to posting its contents on the Register. We remove Educational Undertakings when the physician meets all requirements to the College’s satisfaction. The physician’s registration history reflects the dates an Undertaking was in effect. 

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

Yes. Privacy legislation (Personal Health Information Protection ActQuality of Care Information Protection Act, 2004, and Personal Information Protection and Electronic Documents Act) does not impact the CPSO’s authority to conduct assessments. Physicians do not require patient consent to share their information with the College for quality assurance assessments. However, we do require patient consent if an assessment involves observing the physician in practice. Any assessor appointed by the QAC is bound by confidentiality. 

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

The initial assessment and first reassessment required by the QAC are of no charge to you. Any subsequent reassessments are subject to a fee.