Out-of-Hospital Premises Inspection Program

Providing Notice

The regulation applies to any physician performing or intending to perform procedures in an Out-of-Hospital Premises (OHP) under the administration of: 

• General anesthesia;
• Parenteral sedation (administered by intravenous, intramuscular or subcutaneous injection);
• Regional anesthesia (except for a digital nerve block); or
• A local anesthetic agent, including, but not limited to:
  • any tumescent procedure involving the administration of dilute, local anesthetic;
  • surgical alteration or excision of any lesions or tissue performed for cosmetic purposes;
  • injection or insertion of any permanent filler, autologous tissue, synthetic device, materials or substances for cosmetic purposes;
  • a nerve block solely for the treatment or management of chronic pain; or
  • any act that is similar in nature to those set out above and performed for a cosmetic purpose.

Before any of these procedures can be performed at an OHP, the medical director must complete the notification form, pay the required $500 fee and pass a premises inspection, which is conducted within 180 days of receiving your notice.

You do not have to notify CPSO if you are only performing the following procedures at the OHP:

• Surgical alteration or excision of lesions or tissue for a clinical purpose, including examination, treatment or diagnosis of disease;
• Minor dermatological procedures including, but not limited to, the removal of skin tags, benign moles and cysts, nevi, seborrheic keratoses, fibroepithelial polyps, hemangioma and neurofibromata;
• Lasik surgeries; or
• Cosmetic procedures not involving general, regional or parenteral anesthesia including, but not limited to, temporary fillers, laser skin resurfacing, botox and sclerotherapy.

OHP Standards

The Out-of-Hospital Premises (OHP) standards and companion documents outline core requirements for the performance of specific procedures in OHPs that do not fall under another regulatory oversight system.

• Program Overview

OHP Standards

• Cooperation with the Out-of-Hospital Premises Inspection Program
• Medical Director
• Physicians Practising in OHPs
• Physical Space
• Drugs and Equipment
• Patient Selection
• Procedures
• Infection Prevention and Control
• Adverse Events
• Quality Assurance

Additional Standards

• Interventional Pain Premises
• Endoscopy/Colonoscopy Premises
• Induced Abortion Care Premises
• Image Guidance When Administering Nerve Blocks for Adult Chronic Pain

Updates or Changes to OHPs

The OHP’s medical director is responsible for notifying CPSO of any changes to the premises.

To make changes or updates to your OHP, please submit a Service Request through your Member Portal.

See the Quick Reference Guide for instructions on how to complete a Service Request.

The medical director must await approval from CPSO prior to implementing any changes.

Staff Affiliation

Physicians who wish to apply to practice at an OHP must notify CPSO via a staff affiliation request. Please log in to the Member Portal and follow the instructions in this Quick Reference Guide. There is a non-refundable fee of $75.

Adverse Events Reporting

Physicians practicing in OHPs are required to report adverse events through the Member Portal within 5 business days of learning of the event.

If you have any questions or need assistance, please contact the OHP team via the Member Portal message centre.

Accreditation Program Contacts

Laurie Reid
Director, Investigations and Accreditation Program
[email protected]

Jennifer Kitchen
Manager, Accreditation Program
[email protected]

Christine Grusys
Supervisor, Accreditation Program
[email protected]

General Program Inquiries
[email protected]

• Reference Guides
  • Opening and Replying to Portal Messages
  • Routine Inspection Orientation Presentation (transcript)

  
  OHP Assessors

  • Case Requirements

  OHP Affiliated Physicians

  • Reporting an Adverse Event
  • Submitting a Staff Affiliation Request

  OHP Medical Directors

  • General
  • Pre-premises Inspection Guide
• General Checklists and Documents

  NOTE: Please ensure you open and complete the forms in the latest version of Adobe Reader; otherwise entered text may not save.

  • Premises Standards Checklist
  • Physician Observational Component: Clinical Observation Form 
  • Patient Chart Assessment Checklist
  • Adult Chronic Pain Management: Clinical Observation Form
  • Patient Chart Assessment Checklist: Interventional Pain Management 
  • Anesthesia Chart Assessment Checklist
  • Adult Chronic Pain Management Premises
  • Endoscopy/Colonoscopy Checklist
  • Induced Abortion Checklist
  • Sample Quality Assurance Minutes
• Infection Prevention and Control Checklists
  • IPAC CORE Elements
  • Reprocessing of Medical Equipment/Devices 
  • Endoscopy
• Routine Inspection Checklist
  • CPSO-OHP Routine Inspection Checklist and Appendix
  • Sterilization and Reprocessing Update