Peer and Practice Assessments

Peer and Practice Assessments are another important component of the QA Program. These assessments play a key role in ensuring that members are meeting the Standards of Practice and providing safe, competent and ethical care.

The Regulated Health Professionals Act (RHPA), 1991 authorizes the QA Committee to appoint assessors to assist in carrying out the QA Program. Assessors are members of the College who are trained to review other members’ practice and assess their knowledge, skill and judgment.

There are several ways in which a member can be selected to undergo an assessment, such as:

  • The member was randomly selected, or
  • The member is selected on the basis of criteria specified by the QA Committee and published on the College’s website at least three months before the member is selected on the basis of those criteria.

If you are selected for a Peer and Practice Assessment, an assessor(s) appointed by the College will visit you at your practice to discuss what is working well, what tasks or procedures you could improve on to ensure that your knowledge, skill and judgment are meeting the standards of practice of the profession.

A Peer and Practice Assessment is meant educative and not punitive. It is an opportunity to identify and discuss areas where the College can support you. It is based on similar criteria as the Self-Assessment and will generally include discussion about your Self-Assessment and Professional Development Log.

Member Action Steps

1. Review the College's standards of practice, policies, guidelines and regulations.

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

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

Assessments typically take half a day (3 to 4 hours) to complete. Plan your schedule to allow for meetings with the assessor(s) and advise clinic staff to help the assessor select patient files for review. The assessor(s) will review up to 10 patient files during the assessment that they will randomly select from your records. Please do not pre-select the records for them.

The assessor(s) will share the findings of the assessment report with you and provide suggestions on how to improve your practice. The report will then be forwarded to College staff to be reviewed by the Quality Assurance Committee. A follow up letter will be sent afterwards advising of any next steps.

Please note that follow up correspondence may take up to 6 weeks.

The QA Committee may determine upon review that there are deficiencies in a members’ knowledge, skill or judgment. If the report is not satisfactory;

  • The 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.

The 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, skill or judgment is still not satisfactory, the QA Committee may require the member to participate in remedial activity, such as 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 must include the following:

  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.

Colleges must establish a QA Committee and make regulations prescribing a QA Program. The RHPA 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 assessors and the QA Committee.

R. TCMPs and R. Acs are registered members of the College. Registration ensures that they have met the professional requirements of the College and are competent to practice. The QA Program ensures that the initial competencies acquired to practice as members of the College are maintained through regular participation in professional development and continuing education activities.

Under section 82 of the Regulated Health Professions Act (RHPA), all registered members are required to participate in the Quality Assurance Program, including the Self-Assessment, Professional Development, and Practice Assessment. If a member does not fully participate in the Peer and Practice Assessment, the QA Committee may refer the matter to the College’s Inquiries, Complaints and Reports Committee (ICRC) 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 are not actively practicing traditional Chinese medicine and/or traditional Chinese acupuncture (i.e., you hold a certificate in the Inactive class of registration), your assessment will be reinstated once you return to active practice.

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.

College appointed assessor(s) can access this information, as 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 patient 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

As per section 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.