Independent Health Facilities – Clinical Practice Parameters and Facility Standards for Diagnostic Imaging – General Consultation

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    Click here to see the proposed changes to the Diagnostic Imaging document.

    The deadline to provide feedback is October 23, 2017.

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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 Diagnostic Imaging” 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 diagnostic imaging 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 Diagnostic Imaging, which is an update to the 2012 document.


    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 diagnostic imaging 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. View the entirety of the proposed changes to the IHF Clinical Parameters and Facility Standards for Diagnostic Imaging.

    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 additions/updates:

    • Volume 1:  Facility Standards 
      • Chapter 1: Staffing a Facility –
        • 1.1 – Staff responsible for the sterilization and reprocessing of medical equipment must be adequately educated and trained (repeated in 3.3.8 Infection Control);
        • 1.5.3 – If a QA has reasonable grounds to believe that the licensee is not complying with the generally accepted standards, the QA must inform the Director, IHF program, Ministry of Health and Long-Term Care.
        • 1.6 – If a QA’s scope of practice does not include all services provided on the IHF’s license, she or he must appoint Medical Lead(s), i.e. physician(s) for each applicable service to assist with IHF staff compliance with policies and procedures set out by the QA.
        • 1.7 – For IHFs providing mammography, the QA is responsible for either assuming the role of Facility Lead (new role) if qualified or appointing a physician who meets the criteria.  The Facility Lead must fulfill specific duties and responsibilities (identified in this section), which relate to a broader provincial quality management program initiative for mammography:
        •  1.8 – This expanded Radiation Protection Officer section now includes duties and responsibilities (previously none specified).
        • 1.9 – This MRTs section reflects updated information regarding accreditation, as well as duties and responsibilities.
        • 1.10 –As of January 2018, the College of Medical Radiation Technologists of Ontario (CMRTO) will begin registering sonographers (refer to the CMRTO website for additional information). Updated information regarding accreditation and credentialing, as well as duties and responsibilities, are included.
        • 1.11 – While there is no legal requirement, IHFs are encouraged to seek out the services of a Qualified Medical Physicist to be part of their Quality Control program.  Details are outlined.
        • Chapter 2: Facilities, Equipment and Supplies –
        • 2.3.1 (Radiography), 2.3.2 (Fluoroscopy), 2.3.3 (Ultrasound) – Acceptance testing, performance evaluation, and quality control requirements have been updated in all sections. Also, there is a new section on quality control recommendations for Computed Radiology & Digital Radiography (
        • 2.3.5 Bone Mineral Densitometry – Acceptance testing details are now included.
        • 2.5 Aging Equipment – Equipment age should conform to the CAR guidelines for life cycle guidance.
        • 2.3.4 Mammography – All facilities providing mammography services must have continuous, uninterrupted CAR-MAP accreditation.
      • Chapter 3:  Policies and Procedures – 
        • 3.3- Policies and Procedures manual must be reviewed and signed off by facility staff and QA annually; in addition, new items/clarifications were made to the bulleted lists in 3.3.3 to 3.3.6. Other key changes include:
          • 3.3.2 – Supervision policies for staff in the process of obtaining credentials, and orientation procedures must exist for new staff.
          • 3.3.9 – All equipment that has direct skin contact i.e. mammography plate is wiped between patients with hospital grade low-level disinfectant solution/wipe; significant updates were also made to the following subsections to reflect Infection Prevention and Control (IPAC) Canada requirements:
            • – There must be a separate reprocessing area for endocavity transducers; new flowcharts added to guide facilities in the necessary steps for reprocessing, as well as documentation requirements.
            • – The IPAC Position Statement on Medical Gels – January 2017 (appendix III) resulted in a number of key changes, e.g.  gels cannot be warmed; containers of gel should never be washed and refilled for use; a new flowchart was added to guide facilities in use of gel.
      • Chapter 5:  Quality Management –
        • 5.1 – includes an expanded list of items that must regularly appear on all Quality Assurance (QA) Committee agendas.
        • 5.4 – Facility Leads have duties and responsibilities relating to quality management for mammography (see Chapter 1).  QA Committee tasks have been revised, and include implementing a quality review process which follows the basic principles of the CAR peer review program.
      • Chapter 6:  11 to 13 Week Ultrasound –This Chapter has been updated to reflect BORN’s new role in quality assurance for the NT scan for all performing sonographers.  All Ontario sonographers performing NT scans will be mandated to participate in this QA program, and the steps to do this are outlined in the chapter.
      • Appendix III:  IPAC Position Statement on Medical Gels – January 2017 is included for information, and replaces “Risk of Serious Infection from Ultrasound and Medical Gels – Notice from Health Canada October 2004”
    • Volume 2:  Clinical Practice Parameters:
        1. Chapter 7:  Position Statement from the IHF Diagnostic Imaging Task Force – IHFs must now visit the Canadian Association of Radiology (CAR) website to access the most up-to-date guidelines (links to specific modality guidelines have been removed);  in the absence of CAR guidelines on a modality, IHFs should then visit the American College of Radiology website for guidance.
        2. Mammography – Facilities providing mammography are reminded that in addition to following Mammography clinical practice guidelines, they must also participate in OBSP.
    • Volume 3: Teleradiology (PACS)
      • CAR Teleradiology Standards – Studies must be physically performed in Ontario and that the reporting radiologist must be in the province at the time of reviewing and reporting.
      • ACR White Paper on Teleradiology Practice: A Report from the Task Force on Teleradiology Practice – replaces ACR Standard for Teleradiology
      • CPSO Telemedicine Policy – the updated (2014) version of this policy is included.

    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 Diagnostic Imaging.  Please be sure to quote the specific numbered sections or subsections to which your comments relate when providing feedback. The consultation deadline is October 23, 2017.  Join the discussion online, send us an email, or send a letter.

    Next Steps

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



    Have your say

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    The consultation deadline is October 23, 2017

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    Send us your feedback by mail:

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

    Attention: IHF Diagnostic Imaging