The role of the Medical Director is essential to ensuring safe and quality care within an OHP. The quality of the leadership and oversight of the OHP correlates with the quality of the care provided within the OHP.

Accordingly, many of the expectations set out within the OHP Standards are the responsibility of the Medical Director. This companion Advice to the Profession document (Advice) is intended to help Medical Directors interpret their obligations as set out in the Medical Director Standard and provide guidance around how the expectations may be effectively discharged.

The Medical Director Standard sets out minimum criteria that must be met in order to be a Medical Director. If I meet the minimum criteria, will I automatically be approved to be a Medical Director?

No. Satisfaction of minimum criteria does not guarantee approval to be a Medical Director. CPSO will exercise reasonable discretion in approving Medical Directors. Additional considerations may include, but will not be limited to, whether: 

• a physician has active investigation(s) and the nature of the investigation(s) (g. whether the complaint has a specific impact on the ability to perform in the role);
• a physician is subject to any other regulatory activity or condition that may be relevant to the role; 
• a physician is the subject of a discipline finding; 
• a physician has had their certificate of registration revoked or suspended;
• the number of OHPs a physician is currently holding the role of a Medical Director for.

The Medical Director Standard requires that Medical Directors have the skills and experience necessary to effectively oversee the OHP. What are the skills and experience necessary to oversee an OHP?

Relevant skills needed to be effective in the role include strong leadership skills, relevant clinical expertise, and knowledge of relevant clinical practice guidelines, quality improvement, and infection prevention and control standards. There are a variety of ways in which the necessary skills and experience can be acquired.  While some Medical Directors may have such knowledge, skills and experience before taking on this role, others may acquire the skills over time. For those seeking additional training to help develop the necessary skills, professional development is available.  For example, leadership training is offered through programs such as the Canadian Medical Association’s The Physician Leadership Institute.

I’m considering hiring a regulated health professional whose certificate of professional conduct (CPC) indicates they have an active investigation. Am I permitted to hire them?

It depends. The Medical Director Standard sets out minimum criteria that must be met for staff practising in an OHP. Given that Medical Directors are responsible for their staff and all of the care provided in the OHP, even if these criteria are met, Medical Directors will need to use their professional judgement and carefully consider the nature and seriousness of the complaint or investigation and how quickly it will be resolved.

Medical Directors are responsible for ensuring their staff are appropriately qualified and have the competence necessary to practise safely in an OHP. Depending on the nature and seriousness of the complaint or investigation (e.g., whether there are concerns about clinical competence) Medical Directors may wish to hold off on hiring the individual until the outcome of the investigation is known, or to take additional steps to satisfy their obligation to ensure the individual’s competence. Medical Directors are ultimately responsible for the care provided in the OHP and for exercising due diligence when hiring.

What happens if CPSO determines that a Medical Director cannot fulfill their duties?

The Medical Director is accountable for fulfilling all of their obligations and duties to the OHP and CPSO. In the event that CPSO determines that the Medical Director is not performing their duties in accordance with the legislation, regulations, and policies, CPSO can require the OHP Medical Director to appoint an Acting Medical Director acceptable to CPSO and/or take such other steps as deemed necessary.

If a Medical Director goes on vacation, will they need to appoint an Acting Medical Director to fulfill their duties?

Whenever a Medical Director is unable to fulfill their duties as set out in the OHP Standards, they are required to ensure that another physician practising in the OHP will fulfill these duties. If the Medical Director will be unavailable or unable to fulfill their duties for one month or more they are required to notify the CPSO and where deemed necessary, appoint an Acting Medical Director who meets the criteria set out in the Standard and who is approved by CPSO. Temporary or short-term absences (less than a month) do not require the appointment of an Acting Medical Director that is approved by CPSO but do require the Medical Director to designate a physician within the OHP to perform their role while they are unavailable.

Medical Directors are required to be on site as needed, but at least one day per month, to oversee the premises and ensure the OHP is operating safely and effectively. What kind of things would a Medical Director be doing when they are on site?

There are a number of responsibilities that Medical Directors have with respect to the OHP, including those related to supervision, quality assurance, and infection prevention and control. In order to effectively fulfill these duties, it is important that Medical Directors are on site as needed to oversee the premises, ensure that policies and procedures are being adhered to and to ensure that safe, quality care is being provided. The more present and involved a Medical Director is within the OHP, the better the patient care tends to be.