Those working in OHPs, including Medical Directors, have a duty to co-operate with the CPSO, to communicate promptly and accurately with CPSO, to foster a respectful relationship and demonstrate co-operation with the Out-of-Hospital Premises Inspection Program (OHPIP). Failure to co-operate, communicate with, or provide information to CPSO in the required manner may result in an outcome of Fail by the Premises Inspection Committee, which requires the OHP to cease operation of all OHP procedures, or may trigger a reinspection or a referral to CPSO’s Inquires, Complaints, and Reports Committee.

Standards

1. All physicians practising in OHPs must:
   1. provide accurate information to CPSO, in the form and timeframe specified by CPSO;
   2. co-operate with inspections undertaken by CPSO in order to ensure compliance with the OHP Standards.
2. Medical Directors must annually confirm, in the form and manner required by CPSO, their understanding of their responsibilities as set out in the OHP Standards and that they are compliant with these responsibilities. This will include agreement to:
   1. perform their duties with due diligence and in good faith;
   2. ensure that the OHP complies with the OHP Standards and meets its responsibilities;
   3. ensure the OHP provides safe and effective care.
3. Medical Directors must respond to CPSO requests for documentation and information in the form and timeframe required, as follows:
   1. within 5 business days for information regarding adverse events;
   2. within 14 days for regular CPSO requests; or
   3. any otherwise specified timeframe as identified by CPSO for other CPSO requests.
4. Medical Directors must ensure the OHP does not:
   1. operate in contravention of the OHP Standards; and/or
   2. operate in contravention of any conditions or restrictions imposed by the OHPIP and/or the Premises Inspection Committee.
5. Medical Directors must ensure OHPs cease performance of all OHP procedures if they receive a fail outcome from an inspection.
6. All physicians planning to practise in an OHP must complete the online Staff Affiliation form prior to performing procedures in an OHP.

Notification to CPSO

7. Medical Directors who plan to operate a new OHP must notify CPSO of their plans to do so.
8. Medical Directors must ensure that no procedures are performed in the OHP until they receive approval from the OHPIP to do so and that only approved OHP procedures are performed.
9. Medical Directors must ensure that CPSO is notified in writing of any adverse event in the OHP within 5 business days of learning of the event.¹
10. Medical Directors must notify CPSO in writing at least two weeks prior to making any of the following changes to the OHP or as soon as reasonably possible:
    1. ownership of the OHP;
    2. name of the OHP;
    3. numbers of procedures performed: any significant increase/decrease (>50% of the last reported inspection);
    4. a new arrangement to rent space to other physicians intending to perform OHP procedures;
    5. decision to cease operation of the OHP²;
    6. intention to provide extended or overnight stays³.
11. Medical Directors must notify CPSO in writing at least two weeks or as soon as reasonably possible prior to any of the following intended changes to the OHP and receive approval (and where necessary undergo a re/inspection):
    1. OHP Medical Director (in accordance with the Medical Director Standard);
    2. OHP location/address;
    3. structural changes to patient care areas (including equipment);
    4. addition of new OHP procedures.

Inspection Process

12. Medical Directors and physicians practising in the OHP must participate fully in the inspection process and comply with CPSO requests in relation to this process, including:
    1. submitting to an inspection of the OHP;
    2. promptly answering any questions or complying with any requirement of the inspector that is relevant to the inspection;
    3. co-operating fully with CPSO and the inspector who is conducting the inspection;
    4. providing the inspector with any requested records;
    5. allowing direct observation of a physician, including direct observation by an inspector and/or assessor of the physician performing a procedure on a patient;
       1. Where observation will be occurring, Medical Directors must ensure that the patient is informed in advance of the scheduled procedure that an observation of the procedure may take place as a component of the inspection process and that written consent to the observation has been obtained.
13. Medical Directors must ensure that complete records are onsite and available to the CPSO and inspector on the date of planned inspections, including all books, accounts, reports, records, or similar documents that are relevant to the performance of a procedure done in the OHP.
14. Medical Directors must be on site during inspections, where requested.
15. Medical Directors must participate in any requested post inspection processes (e.g., an exit interview with the inspector, completion of a post inspection questionnaire, and providing any required follow-up documentation).

Endnotes

^1. Please see the Adverse Events Standard for more information.

^2. For more information on the appropriate steps to follow when ceasing operation, please see CPSO’s Closing a Medical Practice policy. 

^3. An extended or overnight stay is where a patient has not met discharge criteria and is required to stay in the OHP beyond normal operating hours.