Proposed Changes to OHPIP Standards (Consultation Closed)

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    The College is seeking feedback on draft amendments to Out of Hospital Premises Inspection Program (OHPIP) Standards that, if passed, would enhance the responsibility and accountability of the Medical Director, and address matters concerning quality assurance, infection control and staff qualifications. We invite physicians, other health care professionals, and the general public to leave comments on this consultation’s discussion board about these proposed amendments.

    Background and Proposed Standards Changes

    The Out-of-Hospital Premises Inspection Program (OHPIP) supports continuous quality improvement through developing and maintaining standards for the provision of medical care/procedures in Ontario out-of-hospital premises and by inspecting and assessing for safety and quality of care. The OHPIP Standards document articulates the core requirements for procedures using anesthesia as defined in Ontario Regulation 114/94 in settings/premises outside of a hospital that do not fall under another regulatory oversight scheme.

    The Medical Director is the main contact for any information related to out-of-hospital premises. The OHPIP Standards document sets out the responsibilities of the Medical Director with respect to administrative duties, quality assurance, and emergency responses.

    The College is proposing key changes to the OHPIP Standards that would enhance the responsibilities and accountability of the Medical Director in areas of quality assurance, infection control and staff qualifications. The proposed changes are limited to Section 2 (OHP Background), Section 5 (OHP Staff Qualifications), Section 7 (Infection Control), and Section 8 (Quality Assurance).

    Overview of Proposed Changes

    Below is a summary of the key proposed changes to the OHPIP Standards document. View the entirety of the proposed changes to the OHPIP Standards document.

    1. Appointment of Acting Medical Director
            • If the Medical Director is unable, or unavailable to perform his or her duties, then he or she must appoint an Acting Medical Director who is acceptable to the CPSO; this individual must sign an agreement which details the full scope of his or her responsibilities. However, quality assurance responsibilities cannot be assigned to an Acting Medical Director by the Medical Director.
            • If the CPSO determines that a Medical Director (or Acting Medical Director) is not performing his or her duties, the CPSO may require the Medical Director to appoint an Acting Medical Director acceptable to the CPSO, or take other steps as deemed necessary.
            • The Medical Director must notify the CPSO of any changes to the Medical Director role within 48 hours of the change.
    2. The Medical Director is now not only responsible for reviewing and updating, but also ensuring implementation of said policies and procedures at the OHP. There is now a requirement that all OHPs have detailed and clear patient selection/admission/exclusion criteria.
    3. Physicians with disciplinary or incapacity proceedings are precluded from becoming a Medical Director. Additionally, the onus is on the physician to self-report should this happen in the course of serving in the Medical Director role.
    4. Infection Control
            • Additional wording has been added to emphasize Medical Directors’ responsibility for ensuring implementation of and compliance with infection control requirements by all physicians and staff of the OHP. This includes periodic reviews of the CPSO and Public Health Ontario website documents by the Medical Director, staff, and physicians working in the OHP.
    5. Recognizing that a Medical Director may not necessarily be qualified to provide services or opine on quality of services in the OHPs that he or she oversees, the Medical Director may “appoint other individuals as necessary to assist” with monitoring and reporting on the quality of anesthetic and surgical procedures.
    6. A new requirement that the Medical Director must attend and chair a minimum of two Quality Assurance (QA) Committee meetings per year at each OHP, along with a minimum list of standard topics to be included on every QA agenda.
    7. A Medical Director’s failure to provide information to the CPSO may result in an outcome of “Fail” by the Premises Inspection Committee. This includes responding to adverse events and regular CPSO requests.

    Have Your Say

    We would like to hear your thoughts on the proposed key changes to the OHPIP Standards document. Join the discussion online, send us an email, or send a letter.

    Next Steps

    The College’s Executive Committee and Council will carefully consider your comments before making any decisions about the proposed changes. The College will consider the extent to which your suggestions or comments represent the expectations of the profession, and are consistent with our public interest mandate. If, after consultation, the proposed changes are passed by Council, notification and a copy of the finalized Standards document will be posted on the College’s website.

    To ensure transparency, the College will post consultation feedback responses on our website, in accordance with our posting guidelines.

    Names of individual participants will not be posted, however the names of organizations will be posted. Check our website for further detail about our consultation process, and to view a copy of our posting guidelines.



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    College of Physicians and Surgeons of Ontario
    80 College Street
    Toronto, Ontario

    Attention: OHPIP Amendments