College of Physicians and Surgeons of OntarioQUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

IHF Program Updates

Tracey Marshall, SupervisorPractice Assessment & Enhancement Department

College of Physicians and Surgeons of Ontario

College of Physicians

and Surgeons of Ontario

Assessment Process ChangesChanges implemented for 2015/2016 Cycle

Facilities will be referred to the website to obtain tools and protocols for assessments Completed PVQ’s and Policies and Procedures Manual should be submitted to the assessor(s) on a CD or USB stick Documents cannot be submitted to the assessors via e-mail

Sleep Medicine AssessmentsPre-assessment Questionnaires must be submitted to the College College will verify Sleep Medicine Physician qualifications and will confirm with the appointed assessors prior to the on-site assessment.

*(It is important that the physician PVQ be submitted in a timely manner.)

College of Physicians

and Surgeons of Ontario

Assessment Process Changes Following the on-site assessment

Assessment reports are sent to the licensee; important for licensee’s to provide an updated e-mail address for communication with the College IHFs have 14 days to respond to their assessment report prior to the report being reviewed by the Facility Review Panel and IHF Director Facilities have the opportunity during this timeframe to review, respond and correct any possible deficiencies outlined in the report. Any submissions from the facility are included as provided to the IHF Review Panel for consideration

College of Physicians

and Surgeons of Ontario

Assessments: Trends and IssuesStaff

The College has adopted Sonography Canada’s Credentialing as well ARDMS Technologists with the CRGS (Generalist) Technologists with the CRGS (Limited)

BMD Certification – at present there is no requirement to recertify your training

College of Physicians

and Surgeons of Ontario

Assessments: Trends and Issues Peer Review

Awaiting results and recommendations from the Health Quality Ontario review. Facilities are still required to have a documented mechanism of a peer review program in place

College of Physicians

and Surgeons of Ontario

OHP/IHF: Joint Assessment ProcessRegulation amendment resulted in the move to a joint regime for the assessment of OHPs/IHFs (September 2014)

Facilities affected by the change in regulation:Abortion CarePlastic SurgeryCataractColonoscopyGynecology proceduresIVF

College of Physicians

and Surgeons of Ontario

OHP/IHF Joint Assessment ProcessQuality standards have been updated:

Standards have been incorporated into the OHPIP companion document: Applying the Out-of-Hospital Premises Inspection Program (OHPIP) Standards in Endoscopy/Colonoscopy Premises and Independent Health Facilities (IHFs)

Applying the Out-of-Hospital Premises Inspection Program (OHPIP) Standards in Induced Abortion Care Premises and Independent Health Facilities (IHFs)

Additional Standards will be developed as required to support the joint regimeAssessments using the updated standards to begin in the 2016/2017 Fiscal year, or sooner

College of Physicians

and Surgeons of Ontario

Infection Control Guidelines

Infection Prevention and Control for Clinical Office Practice (2013) was developed by The Provincial Infection Diseases Advisory Committee on Infection Prevention and Control in collaboration with the CPSO

College of Physicians

and Surgeons of Ontario

Public Health Ontario

Document outlines best practices related to:Principles of infection control in a clinical office settingLegislation relating to clinical office practiceResponsibilities of physicians as employers and supervisorsConsiderations when setting up a new clinical officeRationale and tools for screening and risk assessment for infectionRecommendations for providing a clean clinical office environmentGuidance for reprocessing of reusable medical equipmentProtection and safety issues related to staff

College of Physicians

and Surgeons of Ontario

CPSO: Additional IPC InitiativesIncorporating IPC Survey tool into Peer Assessment Program

Self Assessment with Educational Component

Development of Tools and ResourcesIPC Checklist to be incorporated into assessment protocol

Contributed to Community IPC Lapses Investigation Document

Joint Inspections with Public Health Units across Ontario

Development of Database for tracking of all IPC concerns

Education and Training of Assessors and InvestigatorsFacilitated by Public Health Ontario

College of Physicians

and Surgeons of Ontario

Updating CPPs and Facility StandardsPulmonary Function Studies CPPs and FS – updated June 2014CPPs and FS in process of being updated:

Sleep Medicine

Computed Tomography and Magnetic Resonance Imaging – external review completed. Final document prepared by end of 2015

Upcoming CPP Revisions for 2016Diagnostic ImagingNuclear Medicine – including PET and CTLaser Treatment for Benign Vascular LesionsChronic Kidney Disease

College of Physicians

and Surgeons of Ontario

IHF Program ResourcesAvailable on the CPSO Website

www.cpso.on.ca (located under Members tab)

Clinical Practice Parameters and Facility StandardsAssessment Tools (PVQ & Protocols) – PVQ’s are fillable PDF

Roles and Responsibilities of the Quality AdvisorGuide to submitting a written Plan of ActionSample Quality Advisory Committee Agenda templateSample QAC minutes template IHF/OHP Newsletter – quarterly updates

College of Physicians

and Surgeons of Ontario

IHF/OHP Program: Staff Contacts• IHFP Staff:

• Shandelle Johnson – Manager sjohnson@cpso.on.ca• Tracey Marshall – Supervisor tmarshall@cpso.on.ca• Nadia Mura – Assessment Co-ordinator nmura@cpso.on.ca• Jennie Sun – Program Assistant jsun@cpso.on.ca

• OHPIP Staff:• Shandelle Johnson – Manager sjohnson@cpso.on.ca• Christine Grusys – Supervisor cgrusys@cpso.on.ca• Kimberly Mistysyn – Assessment Co-ordinator kmistysyn@cpso.on.ca• Elza Ramos – Program Assistant eramos@cpso.on.ca• Paige O’Brien Welker – Assessment Co-ordinator pobrien@cpso.on.ca • Chrissie Ramoutar -Program Assistant cramoutar@cpso.on.ca• Sharon Lawrence Palmer – Assessment Co-ordinator spalmer@cpso.on.ca• Katrina Oliver 0Assessment Co-ordinator – (on leave)