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FAQS: Quality Improvement Program for Individuals

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Right-Touch Regulation & the QI Program

What is "right-touch regulation"? Why is CPSO phasing out random peer and practice assessment?

  • Right-touch regulation is CPSO’s adopted approach to regulating the practice of medicine in Ontario.
  • In line with Right-touch regulation, CPSO is implementing a risk-informed approach to quality that addresses risk factors associated with the delivery of safe care.
  • CPSO’s QI Program focuses on: A) preventative/proactive self-assessments & B) practice assessments that are focused and are conducted only when necessary.
  • A preventative/proactive approach will encompass greater aspects of self-directed learning and replaces traditional office-based random peer and practice assessment.
  • The QI Program provides physicians with access to easy-to-use, online self-assessment modules to support identifying opportunities for practice improvement.
  • Only when necessary will a more focused assessment, such as a peer and practice assessment, be directed.

Is this QI Program mandatory? Can I withdraw part way? Will there be consequences if I withdraw?

  • It is important that members periodically engage in quality improvement and/or quality assurance activities.
  • While the QI Program activities are not currently mandated by regulation, members are highly encouraged to participate.
  • Members who choose not to participate in the QI Program may instead be required to undergo a peer and practice assessment as directed by the CPSO Quality Assurance Committee. CPSO members are required to participate in quality assurance activities under the Regulated Health Professions Act, 1991 (RHPA).

Physician Selection/Eligibility

Why was I selected? Was I selected for the QI Program because of specific concerns regarding my practice?

  • No, you were not selected because of any specific concerns regarding your practice. You are part of a random group of physicians chosen to participate in the QI Program this year.
  • Every year, approximately 20% of eligible physicians are engaged through the QI Program.
  • Members are eligible for participating in the QI Program if they have been in practice for five or more years and they are under 70 years of age.

What does it mean that I am not required to participate in the Quality Improvement Program again for five years?

  • The QI Program is based on a 5-year cycle. All eligible CPSO members are asked to complete their QI Program requirements once every 5 years. After completing the QI Program, the next time you would be eligible for participation will be in five years’ time.
  • We encourage you to undertake regular quality improvement on your own initiative.

I am 69 or will be retiring soon? Should I participate in this program?

  • All physicians up to the age of 70 are eligible to participate in the QI Program.
  • At age 70, members are engaged through the Quality Assurance Program and complete a mandatory peer and practice assessment. Members engaged in age-targeted assessments are not required to complete the QI Program.
  • If you intend to retire, please contact program staff to discuss your timeframe.

In recent years, I have left full-time practice and now work part-time or on an intermittent basis (e.g., long-term care, locums, etc.). Do I still need to complete the QI Program?

  • The QI Program is designed to be relevant to any member providing direct care to patients.

I share my practice with another physician. Will this impact my involvement in the program?

  • This will not affect your participation in the program.
  • Participation is on an individual basis.
  • As the QI Program evolves there may be opportunities to explore group-based quality improvement activities with the potential to involve multiple physicians in the same practice location.

What if my practice was recently assessed through a CPSO assessment or inspection program (e.g. peer and practice assessment program, Out-of-Hospital Premises Inspection Program)? Do I still need to participate in the QI Program?

  • Participation in facility inspection programs has no bearing on members’ requirements to complete the QI Program.
  • If you have been contacted to complete QI Program requirements, but your practice has been assessed through a peer and practice assessment within the past 5 years, please contact the program.

I would like to participate in this program, but I have not been contacted by CPSO, how can I go about participating?

  • Eligible members participate in the QI Program on a 5-year cycle. If you are not currently participating, you will have an opportunity to participate in the future.
  • Other specialties and scopes of practice will be added to the QI Program in upcoming years.
  • If you have a particular reason for wanting to participate in the QI Program, please contact the program and we will review your eligibility to participate.

Completion Timelines/Deadlines

What is the timeline for the completion of QI Program requirements?

  • You may complete the program at your own pace during your allotted timeline. You will have approximately 3 months to complete the QI activities and submit your practice improvement plan. You will be sent a reminder when your 3-month period begins as well as reminders as your completion deadline approaches.

I am just too busy to participate, what should I do?

  • We understand that your schedules are demanding. That is why we created this flexible QI Program that you can complete at your own pace as opposed to a traditional peer and practice assessment.
  • Based on feedback from your peers who participated in the QI Program, we anticipate the overall time commitment to be approx. 12 hours. Given that you will have 3 months to submit a Practice Improvement Plan (PIP), this translates to approx. 1 hour per week to complete the: QI Survey, Practice Profile, Self-Guided Chart Review, Data Driven QI, and Practice Improvement Plan.
  • 83% of respondents from a pilot of the QI Program indicated that the time needed to complete the QI Program was reasonable.
  • Approximately 88% of respondents indicated that overall, completing the QI Program was valuable for learning, for identifying areas for practice change, and for their continuous quality improvement.
  • In light of the above, we would strongly encourage participation in the QI Program.

Extensions or Deferrals

What happens if I cannot complete the program this year?

  • If you are unable to finish the program, extensions may be granted, and program staff will connect with you to explore what additional options may be available to provide you with support.

I would like to be deferred or exempted from the QI Program; how would I go about getting this approved?

  • Please email [email protected] to provide us with additional details.
  • QI Program staff will evaluate your request and will confirm next steps.

CPSO Standing

Will this affect my standing with CPSO, i.e., is there going to be any action depending on information I share or the outcome of my participation?

In certain cases, a member may have learning needs that are beyond the scope of the QI Program. In such cases, members may be engaged through other CPSO programs (such as a peer and practice assessment through the Quality Assurance Program) to help ensure any learning needs or practice issues are addressed.


Compensation/CPD Credits

Will CPSO compensate me for my time to complete the QI Program? Is the peer providing me with feedback compensated?

  • CPSO will not financially compensate you for completing the program.
  • Upon completion of the QI Program activities, both you and the colleague providing you with feedback will be eligible for CPD credits (please see the QI Program CPD Credits page).

Travel/Onsite Practice Visits

Will I be required to travel anywhere, or attend meetings? Alternatively, will someone from CPSO be visiting my practice?

  • In-person meetings or travel is not mandatory/required.
  • There may be a coaching component during your participation. This aspect of the program would be conducted via telephone with a CPSO Medical Advisor/QI Coach who is also a physician.
  • The QI Program will not involve anyone from CPSO visiting your practice.


Who are CPSO Medical Advisors/QI Coaches?

  • A CPSO Medical Advisor/QI Coach is a physician who will be reviewing your Practice Improvement Plan and conducting coaching, if needed.
  • CPSO Medical Advisors/QI Coaches have also been trained in QI activities as well as physician coaching.


What type of device or hardware (e.g. Desktop, Laptop, or tablet) do I need to complete the QI Program?

  • We recommended using a desktop, laptop or tablet to complete the QI Program activities. CPSO does not recommend using a mobile phone.
  • You will require a device that has a PDF reader such as Adobe (this comes standard on most devices)
  • A good quality internet connection to access the CPSO Learning Management System is also important.

Do I need to download any software to complete the QI Program?

  • The QI Program works on both Windows and MAC computers.
  • Please use Chrome as the web browser for the best experience — whether you are using Windows, or MAC.
  • The Learning Management System has autosave functionality as long as you use the Google Chrome browser.
  • After resuming a tool, you may see a pop-up window asking you to confirm whether you want to save answers entered in a previous session. Be sure to click “yes” to be taken to the portion of the tool where you left off.

Who will have access to my data?

  • CPSO only has access to the QI Program Survey and the Practice Improvement Plan, which will be formally reviewed.
  • CPSO Medical Advisors/QI Coaches review this information to provide feedback on your Practice Improvement Plan and offer any necessary support.

Contact Us

If I have a question or need assistance related to the QI Program, who do I contact?

  • We are here to help! The CPSO QI Program Administration Team can be reached by telephone at 416-967-2648 and email: [email protected].
  • Please include your last name and CPSO number in your communications.
  • The QI Program team works to respond to messages within one business day.