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Peer and Practice Assessments

The goal of the Quality Assurance Program is to protect the public by working in partnership with R. TCMPs and R. Acs to support and provide them with tools to demonstrate their ongoing competence. The Regulated Health Professionals Act requires a regulatory health professions College to establish a Quality Assurance Committee. It authorizes the QA Committee to appoint assessors as part of the Quality Assurance Program

CTCMPAO randomly selects members to participate in the program based on selection criteria and matches the selected member with an assessor who holds a certificate of registration with the same title and designation as the member. E.g. 1) a R.TCMP may assess a R.TCMP or a R. Ac, 2) a R. Ac can only assess a R. Ac.

Two designated “Peer and Practice Assessors” will visit your clinic at a mutually agreed time to review the physical aspects of your practice setting, ask you a variety of questions designed to help you reflect on your practice, review the contents of randomly selected patient records and provide you with useful feedback on how to improve your practice.

Peer assessments are meant to be educative and take a more informative approach and is not punitive. Peer assessors are fellow practitioners who act as mentors that provide valuable information on how to better your practice.

Member Action Steps

1. Review CTCMPAO’s regulations, standards of practice, policies and guidelines.

2. Send the following items to CTCMPAO (addressed to the Quality Assurance Committee) within 30 days of receiving notice for the date of the assessment:

  • Completed Self-Assessment Tool;
  • Completed Professional Develompent Plan;
  • A copy of a patient file with names and personal information redacted; and
  • A blank sample of a patient treatment record.

Plan your schedule to allow for meetings with your assessors and advise clinic staff to help the assessor select patient files for review. The assessor will review up to 10 patient files during the assessment that they will randomly select from your records. You will not be able to pre-select the records for them.

The peer assessors will share the findings of the assessment report with you and provide suggestions how to improve your practice and note any suggestions they may have. The report will then be forwarded to the Quality Assurance Committee for review at the next meeting of the committee. A follow up letter will be sent to you after the committee reviews the report, it will advise you of the next steps. Please note that the Quality Assurance Committee meets once a month, any follow up correspondence may take 4-6 weeks.

QA Committee may determine that one or more of the members’ knowledge, skills or judgment is not satisfactory;

  • QA Committee will advise the member of the decision in a written report and will provide the member with 30 days from the date of receiving the notice to make a written submission to the Committee. Given the complexities of mail delivery, the member will be given 10 days to accommodate Section 39 (2) of the RHPA.

QA Committee will review and consider a written submission submitted by a member. If the Committee is of the opinion that the member’s knowledge, skills or judgment is still not satisfactory, the QA Committee may require the member to participate in remedial activity –including specified education, refresher or continuing education programs, courses or initiatives.

The Quality Assurance (QA) Program is an important aspect of the College’s mandate. All Colleges under the Health Procedures Code, Schedule 2 of the Regulated Health Professions Act, 1991 (RHPA) must:

  • develop, establish and maintain programs and standards of practice to assure the quality of practice of the profession: and
  • develop, establish and maintain standards of knowledge and skill and programs to promote continuing evaluation, competence and improvements among the members.

The QA Program for all Colleges must include:

  1. continuing education or professional development designed to:
    1. promote continuing competency and continuing quality improvement among the members;
    2. promote inter-professional collaboration;
    3. address changes in practice environment; and
    4. incorporate standards of practice, advances in technology, changes made to entry to practice competencies and other relevant issues in the discretion of the Council;
  1. self, peer and practice assessment;
  2. a mechanism for the College to monitor members’ participation in, and compliance with the quality assurance program.

The RHPA requires a health professional College to establish a Quality Assurance Committee and to make regulations prescribing a QA program. It authorizes a QA Committee to appoint assessors for the purpose of the QA program. All members of the College are required to participate in the QA program and to cooperate with the assessors and the Quality Assurance Committee.

TCMPs and R. Acs are members of the CTCMPAO. Registration ensures that they have met the professional requirements of the College and are competent to practice. The QA program ensures that R. TCMPs and R. Acs initial competencies acquired to practice as members of the College are maintained through members engaging in professional development and continuing education activities that relate to the practice of the profession.

Under section 82 of the Regulated Health Professions Act (RHPA), all registered members are required to participate in the Peer Practice Assessment Program. If a member does not fully participate in the Peer Practice Assessment Program, the QA Committee may refer the matter to the College’s Inquiries, Complaints and Reports Committee for consideration of professional misconduct.

If you actively practice traditional Chinese medicine and/or traditional Chinese acupuncture (i.e. you do not hold a certificate in the inactive class of registration), your assessment will entail a review of current patient files and your knowledge of CTCMPAO regulations, standards of practice, policies and guidelines.

If you do not actively practice traditional Chinese medicine and/or traditional Chinese acupuncture (i.e., you hold a certificate in the Inactive class of registration), you will undergo a modified assessment. For example, if you do not actively see patients, your assessment would entail a review of your knowledge of CTCMPAO regulations, standards of practice, policies and guidelines.

Pursuant to the Regulated Health Professions Act, 1991, section 36 of the Code any information regarding Peer Practice assessment is confidential and will be shared only with the QA Committee. No other committee will have access to this information.  The QA Committee requires assessors to sign a confidentiality agreement and will consider a breach of this agreement a serious offence.

The right for the College Assessor to access this information is cited in the Health Professions Procedural Code under the Regulated Health Professions Act, 1991 (RHPA), ss.82. (1) (c)

Under ss. 82(2) and 82(3) of the Code, facility operators and health information custodians are required to provide access to premises and charts. This section applies despite any provision in any Act relating to confidentiality of health records (code, ss 82(5).4

Cooperation with Committee and Assessors

82. (1) Every member shall co-operate with the Quality Assurance Committee and with any assessor it appoints and in particular every member shall,

  1. confer with the Committee or the assessor if requested to do so by either of them; and
  2. permit the assessor to inspect the member’s records of the care of patients;
  3. permit the assessor to enter and inspect the premises where the member practises;
  4. give the Committee or the assessor the information in respect of the care of patients or in respect of the member’s records of the care of patients the Committee or assessor requests in the form the Committee or assessor specifies;
  5. participate in a program designed to evaluate the knowledge, skill and judgment of the member, if requested to do so by the Committee.

Further, the Personal Health Information Protection Act, 2004 (PHIPA), clause. 9(2)(e) supports the College’s right of access and states that PHIPA is not be construed to interfere with regulatory activities of the College under the RHPA.