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Medical Director Standard

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Definitions

Medical Director: The Medical Director is the CPSO approved physician responsible for oversight of the OHP.

Acting Medical Director: An Acting Medical Director refers to a CPSO approved physician who is overseeing the OHP in the absence of the Medical Director.

Standards

  1. All OHPs must have a Medical Director or an Acting Medical Director who has been approved by CPSO, and who is responsible for oversight of the OHP, including ensuring compliance with all applicable legislation, regulations, by-laws, CPSO policies, and the OHP Standards.
  2. Medical Directors must annually affirm their compliance with their responsibilities in relation to the OHP, in the manner and form required by CPSO (e.g., complete the Annual Attestation 1).

Qualifications

  1. Physicians acting as a Medical Director in an OHP must have the skills and experience necessary to effectively oversee the OHP 2 and must at minimum meet the following criteria:
    1. reside in Ontario;
    2. hold a valid and active CPSO certificate of registration;
    3. not be the subject of any disciplinary or incapacity proceeding in any jurisdiction;
    4. not have lost their hospital privileges or been terminated from employment for reasons of professional misconduct, incompetence, or incapacity; and
    5. not have any terms, conditions or limitations on their certificate of registration that would impact their ability to fulfill the role of a Medical Director. 3
  2. Medical Directors must inform the CPSO if they become the subject of a disciplinary or incapacity proceeding and may be required to appoint an Acting Medical Director at the discretion of CPSO.
    1. The Medical Director must only resume the role upon CPSO approval.

Appointment of Acting Medical Director

  1. Medical Directors must ensure that whenever they are unable or unavailable to perform their duties, they have designated another physician practising in the OHP to do so.
  2. Medical Directors who plan to take an extended leave of absence or who will be unable to fulfill the duties of their role for one month or more, must inform CPSO, who will then determine whether an Acting Medical Director needs to be appointed.
  3. Where an Acting Medical Director needs to be appointed, Medical Directors must ensure the Acting Medical Director:
    1. meets the criteria set out in provision 3 above; and
    2. is approved by CPSO.
  4. Where an Acting Medical Director is appointed, the Acting Medical Director must affirm their compliance with their responsibilities in relation to the OHP, in the manner and form required by CPSO (e.g., complete an Annual Attestation).
  5. The Medical Director or Acting Medical Director must ensure that all staff working in the OHP are notified when an Acting Medical Director is appointed.

Credentialing and Ensuring Competence

Ensuring competence is a key component of the role of the Medical Director and Medical Directors are ultimately accountable and responsible for all the care provided in the OHP (i.e., for the care provided by the staff practising in the OHP).

  1. Medical Directors must ensure there are policies and procedures addressing the issues set out in Appendix B, and that they are regularly reviewed, updated, and implemented.
  2. Medical Directors must ensure that all staff practising in the OHP have the requisite knowledge, skill, and judgment to do so competently and safely and that they are practising within their scope of practice and any limitations of their certificate of registration.
  3. Medical Directors must ensure all staff practising in the OHP have the appropriate qualifications4 and competence prior to working in the OHP, by at minimum, ensuring the following:
    1. the training and credentials of all staff who wish to practise in the OHP have been reviewed and verified;
    2. all staff are in good standing with their regulatory body, where applicable (i.e., a Certificate of Professional Conduct has been reviewed) including that they:
      1. have a valid and active certificate of registration with their regulatory body;
      2. are not the subject of any disciplinary or incapacity proceeding in any jurisdiction;
      3. have not lost their hospital privileges or been terminated from employment for reasons of professional misconduct, incompetence, or incapacity;
      4. do not have any terms, conditions or limitations on their certificate of registration that would impact their ability to practise in an OHP.
  4. Medical Directors must ensure that current records are kept for each staff member practising in the OHP, including qualifications, relevant experience, and any hospital privileges.
  5. Medical Directors must ensure that all physicians intending to practise in the OHP have notified the CPSO through the Staff Affiliation form.
  6. Medical Directors must ensure that all staff:
    1. read the Policies and Procedures (P&P) manual upon being hired and annually, or where there is a change, and confirm this action (e.g., with a signature and date);
    2. read their individual job descriptions of duties and responsibilities, indicating they have been read and understood (e.g., with a signature and date); and
    3. have professional liability protection as required by their regulatory body, where applicable.

Appropriate Supervision

  1. Medical Directors must provide a level of supervision and support that ensures safe and effective care within the OHP.
  2. Medical Directors must:
    1. be on site as needed, to oversee the premises and ensure the OHP is operating safely and effectively, at least one day per month; and
    2. be readily available to provide appropriate oversight and assistance, when necessary.
  3. Medical Directors must be satisfied that all staff practising within the OHP:
    1. understand the extent of their responsibilities; and
    2. know when and who to ask for assistance, if necessary.
  4. Medical Directors must:
    1. take reasonable steps to ensure that all staff are practising in accordance with the standard of care; and
    2. take appropriate action where there are concerns about the conduct or care of any staff practising in the OHP (e.g., concerns about the number of adverse events), including:
      1. Addressing and documenting the issue with the individual;
      2. Ensuring appropriate remediation;
      3. Suspending or terminating the individual, where appropriate;
      4. Reporting to the professional’s regulatory body, where necessary.

Appendix A: Staff Qualifications

Appropriate qualifications generally include the following:

Qualifications for Physicians Performing Procedures

Physicians who perform procedures using local anesthesia in OHPs will hold one of the following:  

  1. Royal College of Physicians and Surgeons of Canada (RCPSC) or College of Family Physicians of Canada certification that confirms training and specialty designation pertinent to the procedures performed;   
  2. CPSO recognition as a specialist that would include, by training and experience, the procedures performed (as confirmed by the CPSO’s Specialist Recognition Criteria in Ontario policy);
  3. Satisfactory completion of all CPSO requirements for a physician requesting a change in their scope of practice (based on the CPSO policy, Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice). This may include physicians who are currently engaged in a CPSO approved change in scope of practice process.

Qualifications for Physicians Administering Anesthesia

Physicians Administering General or Regional Anesthesia or Deep Sedation 

Physicians administering general or regional anesthesia or deep sedation will hold one of the following:  

  1. RCPSC designation5 as a specialist in anesthesia;   
  2. Completion of a program accredited by the College of Family Physicians of Canada under the category of “Family Practice Anesthesia”;
  3. CPSO recognition as a specialist in anesthesia, or other specialty pertinent to the regional anesthesia performed, as confirmed by CPSO’s Specialist Recognition Criteria in Ontario policy;
  4. Satisfactory completion of all CPSO requirements for a physician requesting a change in their scope of practice (based on the CPSO policy, Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice). This may include physicians who are currently engaged in a CPSO approved change in scope of practice process.

Physicians administering general or regional anesthesia or deep sedation will hold current ACLS certification, unless the physician is an anesthesiologist with active hospital privileges.

Physicians Administering Minimal to Moderate Sedation 

Where a physician is not qualified to administer general anesthesia or deep sedation, but is administering minimal-to-moderate sedation, the physician will hold:  

  • Education and experience to manage the potential medical complications of sedation/anesthesia, including ability to:
    1. identify and manage the airway and cardiovascular changes which occur in a patient who enters a state of general anesthesia,
    2. assist in the management of complications, and
    3. understand the pharmacology of the drugs used, and   
  • Current ACLS certification. 

Nurse Qualifications

Nurses working in OHPs will have training, certification, and appropriate experience as required for the procedures performed, including holding qualifications in accordance with those set out in the National Association PeriAnesthesia Nurses of Canada’s Standards for Practice, where applicable, as well as current ACLS if administering sedation to, monitoring or recovering patients. 

Qualifications for Physicians and Nurses Providing Pediatric Care

If pediatric care is provided to children 12 and under, all physician and nursing staff will:

  1. be trained to handle pediatric emergencies; and
  2. maintain a current PALS certification.

If administering or recovering pediatric patients from general or regional anesthesia or sedation, staff will need to have recent clinical experience doing so (i.e., within 2 years).

Reprocessing of Medical Equipment

Staff responsible for the sterilization and reprocessing of medical equipment need to be adequately educated and trained.

Appendix B: OHP Policies and Procedures

The OHP policies and procedures, which must be regularly reviewed, updated, and implemented include the following:

Administrative issues and responsibilities, including:

  1. responsibility for developing and maintaining the policy and procedure manual,
  2. scope and limitations of OHP services provided,
  3. extended and overnight stays, if applicable (including a plan for managing any unplanned extended or overnight stays),
  4. staff qualifications, hospital privileges, and records.

Response to emergencies, including those related to:

  1. need to summon additional staff assistance urgently within the OHP,
  2. fire,
  3. power failure,
  4. other emergency evacuation,
  5. need to summon help by 911, and coordination of OHP staff with those responders.

Urgent transfer of patients, including:

  1. appropriate transportation (e.g., ambulance) and accompaniment (e.g., Most Responsible Physician, OHP staff, etc.), and
  2. timely transfer of relevant documentation/medical records.

Job Descriptions, including:

  1. OHP staff job descriptions that define scope and limitations of functions and responsibilities for patient care; and
  2. Responsibility for supervising staff.

Procedures related to:

  1. Adverse events (i.e., monitoring, reporting, reviewing and response)
  2. Combustible and Volatile Materials
  3. Delegating controlled acts and medical directives
  4. Routine maintenance and calibration of equipment
  5. Infection control, including staff responsibilities in relation to the Occupational Health and Safety Act
  6. Medications handling and inventory
  7. Patient booking system
  8. Detailed and clear patient selection/admission/exclusion criteria for services provided
  9. Patient consent in accordance with CPSO’s Consent to Treatment policy
  10. Patient preparation for OHP procedures
  11. Response to allergic reactions (e.g., latex)
  12. Blood borne viruses in relation to exposure prone procedures (to support post exposure testing and ongoing monitoring)
  13. Safety precautions regarding electrical, mechanical, fire, and internal disaster
  14. Waste and garbage disposal

Forms used

Inventories/Lists of equipment to be maintained

Endnotes

1. Please see the Co-operation with the Out-of-Hospital Premises Inspection Program Standard for more information

2. For more information about the types of skills and experience necessary to effectively oversee an OHP, please see the Advice to the Profession document.

3. For additional considerations please see the Advice to the Profession document.

4. For additional information on appropriate qualifications, please see Appendix A.

5. Physicians who are trained in general or regional anesthesia or deep sedation but who have not been practising in this area for two years or more would be subject to CPSO’s Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy, if they wished to return to this area of practice.