Independent Health Facilities: Clinical Practice Parameters and Facility Standards for Dialysis

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    The deadline to provide feedback is March 19, 2018.

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    In accordance with the College’s regular review cycle, the Independent Health Facilities (IHF) program’s “Clinical Practice Parameters and Facility Standards for Dialysis” have been updated. The document is designed to assist physicians in their clinical decision-making by providing a framework for assessing and treating clinical conditions in dialysis facilities.

    The College is inviting feedback from the profession and other relevant stakeholders on the updated draft IHF Clinical Practice Parameters and Facility Standards for Dialysis, which is an update to the 2010 document. Some of the changes in the document are intended to align content with the Ontario Renal Network standards.


    The primary purpose of this document is to assist physicians in developing their own quality management program and act as a guide for assessing the quality of patient care provided in dialysis facilities.

    The Independent Health Facilities Act (IHFA) gives the College of Physicians and Surgeons of Ontario the primary responsibility for carrying out quality assessments in Independent Health Facilities, which includes responsibility for developing and regular updating of clinical practice parameters and facility standards.

    Key Changes in the Revised Draft Parameters

    The revised parameters now feature numbered sections/subsections within each Chapter for ease of reference, as well as the following significant updates/additions:

    • Since existing IHFs only provide dialysis services, a decision was made to limit the content of the  revised parameters to dialysis alone; as a result, the following sections have been removed:
            • Volume 2: Chronic Kidney Disease Management
            • Volume 3: Dialysis Access, and
            • Volume 4: Home Dialysis Program
            • Appendix II (Surgical Safety Checklist) and Appendix III (Sample Contract for Home Hemodialysis, Home Hemodialysis Acceptance Criteria, and Home Hemodialysis Training Period)


    • Chapter 1: Introduction – this Chapter sets out some new expectations of IHFs:
        • establish relationships with regional centres to ensure patient access to services/resources not available at the IHF; where regional centres are unable to offer services needed by the IHF, the IHF may wish to develop their own formal written guidelines, procedures, or protocols based whenever possible on best practices, and the services the IHF itself is able to provide, and;
        • align their quality of care metrics with those measured/monitored by the Ontario Renal Network for hemodialysis.
    • Chapter 2:  Staffing– In addition to updating staff roles/responsibilities, the following has been added or revised:
        • 2.1 – All staff remains current with the standards for infection control by obtaining online training through Public Health Ontario, which must be done on annual basis, and must be documented/signed-off and maintained on site.
        • 2.1 – IHFs have agreements in place with regional centres to offer those services that the IHF does not provide to patients (also see 4.2.5)
        • – If the Quality Advisor has reasonable grounds to believe the licensee is not complying with the licensee’s obligations to ensure appropriate qualifications of staff, and services meeting the standard, the Quality Advisor must inform the Director of Independent Health Facilities  (emphasized now, but always been a requirement)
        • – In order to determine appropriate Infection Control training of staff, the Quality Advisor must complete Infection Prevention and Control’s Checklist for Infection Prevention and Control (IPAC) CORE Elements in Clinical Office Practice, and verify completion of relevant training by all staff.
        • 2.9 – Administrative Support Personnel– this role would include clerical, administrative and database functions to support patient care and regulatory body requirements of data collection and reporting quality metrics and initiatives to ORN.
    • Chapter 3:  Facilities, Equipment, and Supplies – This Chapter now identifies the CSA Standards that IHFs must meet, as well as the following updates:
        • 3.2.11 – “Additional Services/Supplies” that an IHF may provide (contingent on appropriate resources, space, personnel, policies, procedures and staff training), which includes Medications, Dialysis and medical supplies, and Monitoring.
        • 3.3 – Aging equipment – Equipment should conform to the recommendations of the Ontario Renal Network, which suggests a lifespan of approximately 10 years or 35,000 working hours for a hemodialysis machine.
    • Chapter 4:  Policies and Procedures – this more robust Chapter now outlines a number of areas in which facilities must have policies and procedures, including but not limited to:  General Procedures, Dialysis Services, Regional Renal programs, Equipment Maintenance, and Infection Control; the more significant changes (not the only ones) require that the procedure manual be reviewed and signed off by all staff, licensee and Quality Advisor annually (with revisions being made, as necessary, as well as dated), and that facilities have policies and procedures in place for:
        • 4.2.2 – Appropriate training for staff responsible for cleaning, disinfecting, sterilizing, and/or reprocessing of medical equipment, including manufacturer’s training (see also
        • 4.2.2 – All staff remains current with the standards for infection control by obtaining online training through Public Health Ontario, which must be done on annual basis, and must be documented/signed-off and maintained on site (see also 2.1).
        • 4.2.2 – Safety education/training for medical and non-medical staff (which is documented and maintained on site) that addresses areas mandated by the Ontario Government (AODA, WHMIS 2015, etc.).
        • 4.2.2 – Orientation for all new staff to ensure adequate training (i.e. review of policy and procedure manuals, modality specific protocols, and all safety training), which employees must sign off indicating that they have successfully completed all of the training.
        • 4.2.5 – Copies of Regional Renal Program Transfer policies, as well as an outline of how the IHF collaborates with Regional Renal Program(s) in:
          • setting service plans and standards
          • patients have access to referrals to social, medical, surgical and radiological services
          • medical monitoring quality standards
          • data collection requirements as set out by the Hub/ORN
          • participate in teh Regional Renal Program(s)’ Emergency Management Plan
          • align with provincial strategies to explore and develop safety initiatives and tools to prevent avoidable harm.
        • 4.2.11 – Infection Control – facilities must maintain up-to-date general Infection Control policies (e.g. environmental cleaning, etc.) as well as policies and procedures related to equipment, use of medical gel, hand hygiene, and “at risk” patients.
    • Chapter 5:  Procedure Standards – nothing new added
    • Chapter 6:  Quality Management – this Chapter now called “Quality Management” (previously entitled “Providing Quality Care”) is now more comprehensive, and includes:
        • 6.1 – The Quality Advisory Committee must consist of at least the Quality Advisor, licensee, and a minimum of 2 site-specific Charge health professionals (e.g. nurse, technologist) who provide health services at the IHF.
        • 6.1 – The requirement that Quality Assurance (QA) Committee meets a minimum of 2 times per year (or more often, as needed), and a list of regular agenda items that QA Committee meetings must include; the licensee must also attend all meetings
        • 6.2 – Quality Management Program goals should include, amongst other items, a review by the QA Committee of the availability of the services at regional dialysis programs for services not provided by the facility, i.e. appropriate patient referrals to multidisciplinary team services at regional dialysis programs might include: dietary, medication and personal/social concerns; vascular access creation, monitoring and servicing; potential self-care and home dialysis options; transplant referrals and work-up facilitation, and; conservative/palliative care discussion and management.
        • 6.4 – Components of a Quality Management Program, as well as details on how that program should be monitored.


    • Chapter 7:  Analyzing Patient Outcomes – this Chapter has been revised, and while it still provides guidance to facilities on evaluating patient outcome measures, adequacy of dialysis, analyzing treatment options, and analyzing aggregate patient outcomes, it is now less prescriptive in nature.

    Have Your Say

    The College welcomes feedback from members of the profession and any other stakeholders who wish to comment or propose revisions to the draft IHF Clinical Practice Parameters and Facility Standards for Dialysis.  Please be sure to quote the specific numbered sections or subsections to which your comments relate when providing feedback. The consultation deadline is Monday, March 19, 2018.  Provide your feedback by email, or send a letter.

    Next Steps

    Feedback provided on the draft IHF Clinical Practice Parameters and Facility Standards for Dialysis will assist the College in determining what revisions may be required.  Once the document is finalized, it will be posted to the CPSO website.



    Have your say


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    Attention: Dialysis Standards