FAQs

1. Who are the peer assessors? 

Assessors are physicians supportive of and interested in quality assurance who help the CPSO conduct assessments of its registrants. They undergo a detailed screening and training process. Regular feedback is also provided to our assessors by the Quality Assurance Committee. We make every effort to ensure the closest possible match between the physician’s and assessor’s scopes of practice. 

2. What will occur during the assessment? 

Assessors will do a review of your patient records based on criteria established by regulations, CPSO policies, and relevant clinical practice guidelines and evidence based best practice. This may take up to half a day. Afterwards, a discussion with you will be invaluable for the assessor to gain an understanding of your records, practice nuances, and responses to feedback. In general, the follow up will take about 30-60 minutes. 

3. What are the potential outcomes of the assessment? 

Overall, the majority of physicians who undergo a peer and practice assessment meet the current standards of practice in Ontario. However, some require changes to their practice to meet those standards. Possible outcomes may include: 

• Satisfactory:  The QAC is satisfied with the results of the assessment and concludes no further action is required and/or suggests the physician complete self-directed learning. 
• Opportunity to address the QAC’s concerns: If, after considering the report, the Committee identifies aspects of the physician’s practice requiring additional information, the Committee may give the physician an opportunity to address its concerns by: 
  • Submitting a written response for the QAC’s review, which may include redacted patient chart samples to show improvements made since the peer assessment. The physician may also choose to speak to a CPSO Medical Advisor for assistance in preparing the submission. OR
  • Speaking to a CPSO Medical Advisor to gain a better understanding of the physician’s practice and areas where improvements may be warranted. In these instances, the Medical Advisor prepares a written summary of the conversation. The physician will have an opportunity to review and approve this summary prior to the QAC’s review. 
• Peer and practice reassessment: If the QAC concludes there are still areas that would benefit from further development after the physician addresses its concerns, they may require a peer and practice reassessment. The reassessment will include a patient records’ review similar to the initial assessment, but there will be a focus on whether or not the concerns identified in the previous assessment were addressed. 
• Notice of Intent to take action under HPPC 80.2 (1): If the QAC identifies record keeping and/or patient care concerns, it may use its powers under Schedule 2 of the Regulated Health Professions Act. Before doing so, QAC grants the physician at least 14 days to make a written submission to the Committee.   

Under this statute, the QAC may do one or more of the following. 

• Require the physician participate in a Specified Continuing Education or Remediation Programs (SCERP); and/or 
• Direct the Registrar to impose Terms, Conditions, or Limitations (TCL); and/or 
• Direct the Registrar to disclose the name of the physician and allegations to the Inquiries, Complaints and Reports Committee (ICRC) if the QAC believes the physician may have committed an act of professional misconduct, or may be incompetent or incapacitated.  

In some circumstances, the QAC may invite the physician to participate in a voluntary Undertaking where they agree to complete identified remediation activities, restrict their practice, or, if the member intends to retire, to commit to an agreed upon time in which to do so. This is decided on a case-by-case basis. 

4. Will you share a QAC decision outside CPSO?  

Most of the information collected by or prepared for the QAC is confidential and cannot be shared with the public or other College committees. But in support of the CPSO’s commitment to protecting the public, we must post outcomes on the Public Register that:   

• Require a physician to participate in a SCERP; or   
• Impose TCLs on their certificate of registration (by means of an order or signed undertaking).  

When a physician signs an undertaking with CPSO, they agree to posting its contents on the Register. We remove educational undertakings when the physician meets all requirements to the College’s satisfaction. The physician’s registration history reflects the dates an undertaking was in effect.  

5. In light of privacy legislation, is CPSO permitted to review patient records without patient consent?  

Yes. Privacy legislation (Personal Health Information Protection Act, Quality of Care Information Protection Act, 2004, and Personal Information Protection and Electronic Documents Act) does not impact the CPSO’s authority to conduct assessments. Physicians do not require patient consent to share their information with the College for quality assurance assessments. However, we do require patient consent if an assessment involves observing the physician in practice. Any assessor appointed by the QAC is bound by confidentiality agreements.  

6. Are there costs associated with a peer and practice assessment/reassessment?  

The initial assessment and first reassessment (if applicable) required by the QAC are of no charge to you. Any subsequent reassessments are subject to a fee.