Out-of-Hospital Premises Inspection Program
These standards apply to all physicians performing applicable procedures in an Out-of-Hospital Premise (OHP).
CPSO wants your feedback to help refine our draft OHP Standards. These new draft OHP Standards are 10 separate documents that set out the expectations of OHPs and the physicians who work within them. Please visit the dedicated consultation page for additional information and to provide your feedback.
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 listed 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.
The Out-of-Hospital Premises Inspection Program (OHPIP) standards and companion documents outline core requirements for the performance of specific procedures in OHPs that do not fall under another regulatory oversight system.
- OHPIP Standards
Updates or Changes to OHPs
The OHP’s medical director is responsible for notifying CPSO of any changes to the premises, including:
- Change in Medical Director;
- Addition of new procedures;
- Addition of new equipment;
- Change of OHP level;
- Relocation/new location;
- Rental of space to other physicians; and/or
- Ceasing operations/closing an OHP.
To complete an OHP request/notification:
- Log in to the Member Portal;
- Select the OHPIP tile from the dashboard;
- Select the relevant OHP number;
- Click “OHP Request/Notification” in the left-hand navigation menu; and
- Complete and submit the form.
The medical director must await approval from CPSO prior to implementing any changes.
Adverse Events Reporting
Physicians practicing in OHPs are required to report adverse events through the Member Portal.
Physicians must report the following events within 24 hours of their occurrence or the physician’s knowledge of the event’s occurrence via the OHPIP tile in the Member Portal:
- Death within the premises;
- Death within 10 days of a procedure performed at the premises;
- Any procedure performed on the wrong patient, site or side;
- Transfer of a patient from the premises directly to a hospital for care;
- An unscheduled treatment of a patient in a hospital within 10 days of the procedure performed at a premises;
- A complication, such as infection, bleeding or injury, to other body structures;
- A cardiac or respiratory event during the patient’s stay at the OHP;
- An allergic reaction; and/or
- A medication-related adverse event.
All adverse events are reviewed upon receipt of the report and CPSO will decide if further action is required. We may ask for additional information from the premises, if required.
If you have any questions or need assistance, please contact the OHP team via the Member Portal message centre.
Accreditation Program Contacts
Director, Investigations and Accreditation Program
Manager, Accreditation Program
Supervisor, Accreditation Program
NOTE: Please ensure you open and complete the forms in the latest version of Adobe Reader; otherwise entered text may not save.
- Facility Questionnaire
- 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
Completed by the Medical Director