IHF Program Updates

1. IHF Program Updates Tracey Marshall, Supervisor Practice Assessment & Enhancement Department College of Physicians and Surgeons of Ontario College of Physicians and Surgeons of Ontario QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

2. Assessment Process Changes Changes 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 Assessments • Pre-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.)

3. 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

4. Assessments: Trends and Issues • Staff • 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

5. 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

6. OHP/IHF: Joint Assessment Process • Regulation 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 Care • Plastic Surgery • Cataract • Colonoscopy • Gynecology procedures • IVF

7. OHP/IHF Joint Assessment Process • Quality 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 regime • Assessments using the updated standards to begin in the 2016/2017 Fiscal year, or sooner

8. 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

9. Public Health Ontario Document outlines best practices related to: • Principles of infection control in a clinical office setting • Legislation relating to clinical office practice • Responsibilities of physicians as employers and supervisors • Considerations when setting up a new clinical office • Rationale and tools for screening and risk assessment for infection • Recommendations for providing a clean clinical office environment • Guidance for reprocessing of reusable medical equipment • Protection and safety issues related to staff

10. CPSO: Additional IPC Initiatives • Incorporating IPC Survey tool into Peer Assessment Program • Self Assessment with Educational Component • Development of Tools and Resources • IPC 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 Investigators • Facilitated by Public Health Ontario

11. Updating CPPs and Facility Standards • Pulmonary Function Studies CPPs and FS – updated June 2014 • CPPs 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 2016 • Diagnostic Imaging • Nuclear Medicine – including PET and CT • Laser Treatment for Benign Vascular Lesions • Chronic Kidney Disease

12. IHF Program Resources Available on the CPSO Website • www.cpso.on.ca(located under Members tab) • Clinical Practice Parameters and Facility Standards • Assessment Tools (PVQ & Protocols) – PVQ’s are fillable PDF • Roles and Responsibilities of the Quality Advisor • Guide to submitting a written Plan of Action • Sample Quality Advisory Committee Agenda template • Sample QAC minutes template • IHF/OHP Newsletter – quarterly updates

13. 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)