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Patient Compass

January 2017

Peer Redesign Update: First Peer Redesign Assessments Underway

As of November 2016, four network groups - walk-in clinics, medical psychotherapy, family medicine/general practice, and hospitalists - have finalized their redesigned peer assessment handbooks.

Select assessors in these four networks have already begun testing the handbooks in a limited number of peer assessments so that we can identify any challenges with using the redesigned tools and procedures. All assessors will be notified when the tools are ready for broad use in all peer assessments within their discipline. We expect to finalize peer assessment handbooks in five additional networks – dermatology, cardiology, psychiatry, emergency medicine, and endocrinology – by May 2017.

During the transition from the old to the new assessment tools, assessors may be using the existing tools in one assessment, while using the redesigned handbooks in another. To help avoid confusion, your assessment coordinator will clearly indicate when you will start your first redesign assessment, and your assessment packages will include a checklist to provide a clear reminder of the protocol to be used for each assessment (i.e., old protocols or new handbook). You can also expect extra feedback following your first peer redesign assessment in order to highlight good practices and suggested areas for improvement.

We know it will take time to become familiar with using the new tools and we hope to make the transition as smooth as possible. We would also like to thank all assessors who helped us with the peer assessment redesign project. We would not have been able to undertake this significant change without your participation and expertise. When the transition to the new redesigned tools in these initial nine network groups is complete, we will be inviting other assessor networks to help develop redesigned peer assessment tools for their disciplines. It will take time before each remaining network is engaged in peer assessment redesign, but we look forward to working with all of you soon!

If you have any questions, feel free to contact Will Tays in the College's Research and Evaluation Department..

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Sharing Your Time and Expertise

Wanted: Clinical Supervisors!
The College is looking for members to serve as clinical supervisors. The need for a clinical supervisor often arises as a result of various College committee decisions or policies. In such cases, the College requires the appointment of a clinical supervisor to provide oversight and ongoing assessment of a physician’s practice to ensure that the physician is meeting the expected standard of care and that patient safety is not being compromised. Clinical supervisors may also be responsible for implementing individualized educational plans.

We hope you will consider this additional opportunity to participate in professional regulation. For more information on the role of a clinical supervisor, read our Guidelines for College-Directed Supervision on the College’s website.

If you are interested in finding out more about the clinical supervisor role, please contact Jennifer Irwin, Supervision Lead.

Giving expert advice to the Quality Assurance Committee
When an assessed physician is asked to meet with the Quality Assurance Committee, the Committee may seek the advice of one or two alternate assessors to help them further understand the physician’s scope of practice. In this case, we would contact you and, should you agree to assist the Committee, you would not be commenting on an assessment in which you were the assigned assessor, but instead, you would be selected to act as an additional expert in the scope of practice of another physician under review.

The role requires you to review relevant materials and advise the committee on the typical clinical issues that would arise in a similar physician’s practice as well as give scope specific guidance that can help the Committee assess the physician’s knowledge, skills and judgment. Assessors who agree to assist the Committee in this way will receive an outline of the process they will need to follow to prepare for their meeting with the Committee. It will be important for you to review this information to make sure you understand your role and responsibilities. If you have any questions, please contact Claudia Frisch.

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News from the Quality Management Partnership

Quality report webcasts online
In the fall, the Partnership hosted a series of orientation webcasts to help prepare facilities and physicians for the receipt of their first quality management reports in colonoscopy, mammography and pathology quality management programs (QMPs). Those participating in the webcasts learned about:

  • The purpose and content of QMP reports
  • How to read and interpret the reports
  • The role of QMP Facility Leads and Administrative Contacts with respect to QMP reports
  • Report timelines

If you were unable to participate in the live webcast, you can view the webcast recordings by clicking on the links above or by visiting

In early January 2017, the Partnership will be evaluating the facility quality management reports. If you received a report, we may contact you to ask for your feedback on the report process, which will help inform our understanding of how the reports were used and how they can be improved.

Please email us if you have any questions about the Partnership activities.

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Assessor Notebook

Discussing your assessment findings with physicians
After an assessor reviews the medical records, the next step is an in-depth discussion with the assessed physician about your findings. This discussion, or interview, is a vital part of the assessment as it provides physicians with the context for your conclusions and the opportunity to address any concerns. Assessors should try to structure a fulsome discussion that includes your assessment findings, recommendations and suggestions, as well as a clear narrative about clinical care and record keeping.

When an assessment shows that the physician’s practice is satisfactory, then the discussion is an ideal opportunity to promote continuous quality improvement by validating the care provided and talking about additional opportunities for practice improvement. Finally, don’t forget, in addition to your objective findings, your assessment report should include comments that reflect the nature and scope of the assessment interview and the physician’s responsiveness to your suggestions.


What’s in a name? The GPPA is now the MDPAC - The General Practice Psychotherapy Association (GPPA) recently changed its name to the Medical Psychotherapy Association Canada (MDPAC). Take a look at the updated MDPAC website for more information.

The CPSO after-hours drop box is no more - Assessors in the vicinity of the College’s Toronto office have always had the option of leaving their assessment reports at the College after hours by using the building’s drop slot. However, for security reasons, the College recently removed the drop slot. This means you can now only drop off your assessment reports and other packages during the regular business hours of 8 a.m. to 5 p.m. You can, of course, continue to send your reports to the College through regular mail. Please remember that you must not send reports via email. If you have any questions about the best way to send us your reports, contact Claudia Frisch or your Assessment Coordinator.

Reminder: Changes to Out-of-Hospital Premises (OHP) Standards - In December, the College Council approved an update to the Out-of-Hospitals Premises Inspection Program Standards that increase the responsibilities and accountability of OHP Medical Directors. The changes are limited to Sections 2, 5, 7 and 8 of the Standards, and OHP assessors should review these sections carefully. OHPs will need to comply with the new Standards by June 7, 2017. If you have any questions, please contact the College’s OHP staff.

New rules for expense claims and HST Reimbursement - Effective January 1, 2017, you can only claim and be reimbursed the HST for your attendance, report writing, preparation, and travel time. This change was made to comply with Canada Revenue Agency HST reimbursement rules. The College’s Statement of Services Rendered form has been modified to reflect this change.

Increase to assessor remuneration rate:  The new remuneration rate for physician assessors is $160.00/hour, effective January 1, 2017.

Thank you for being an assessor! In December, assessor certificates and seals were sent to all assessors to say thank you for your contributions and commitment to our assessment programs.

Medical regulation and, indeed, all the work we do at the College can only succeed with the participation of physicians like you. So, thank you for helping ensure our professionally-led model of governance remains vital and healthy. Do let us know if you did not receive your certificate or seal.

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CPSO Policy Consultations – Have Your Say

The College regularly conducts consultations to obtain feedback on new and revised policies, as well as existing policies that are under review. The feedback we receive helps us to assess policies and determine the issues we should consider throughout the review process. The College also often asks for input from physicians and the public when we are reviewing proposed government legislation.

Consultations currently underway include:

Ending the Physician-Patient Relationship
This policy, which is under review in accordance with the College’s regular policy review cycle, sets out the key principles and expectations for physicians when ending the doctor-patient relationship.

Accepting New Patients
This policy, last updated in 2009, is also under review in accordance with the College’s regular policy review cycle. The Accepting New Patients policy sets out physicians’ professional and legal obligations when accepting new patients and emphasizes that physicians must accept new patients in a fair and professional manner.

We hope you will take a moment to review each consultation page and share your comments. You can keep up with all current consultations, submit your comments and review all the feedback received by visiting our consultations page.

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Meet CPSO Assessor Dr. Melvin (Mel) Goodman

Medical Psychotherapy Assessor and Network Lead

Dr. Mel Goodman is a medical psychotherapist and a mentor with the Medical Psychotherapy Association Canada (MDPAC). He is also certified in Cognitive Therapy.

Dr. Goodman has been an assessor since 2001 and has been the Network Lead for medical psychotherapy since 2012. His discipline was one of the first to get involved in peer redesign.

You have been a significant contributor to peer redesign for medical psychotherapy. What can you share with us about your involvement and reflections on peer redesign?
In 2012, I was asked to be the Assessor Lead for medical psychotherapy where I began to work with my colleagues in peer redesign. Our group was one of the earliest peer redesign groups.

We had many meetings over four years, with numerous discussions, reflecting the passionate feelings we brought to our work. There were challenges in peer redesign for psychotherapy because psychotherapy encompasses many different schools and approaches. As such, we had to identify elements of quality care that would be applicable to all the schools of psychotherapy.

After many revisions our resigned tools were sent out for external feedback; we were gratified to receive a significant, positive response to our work from our psychotherapy colleagues.

What valuable information have you gained that would be useful to know for those assessors not yet involved in peer redesign?
I found the discussions with colleagues to be very rewarding. In fact, I consider this to be some of the best continuing medical education that I have received.

To this end, I encourage assessors in other disciplines to take part in this process when your time comes.

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Meet Carolina Law, Committee Support Supervisor, Quality Management Division (QMD)

How long have you been with the College and how has your role evolved?
I joined the College in 2013. I oversee the day-to-day operations of five committees in the Quality Management Division by providing guidance and support to the team of committee coordinators and decision writers. I enjoy learning about the various peer and facility assessment program areas that support each of the QMD committees, such as the Quality Assurance and Premises Inspection Committees.

The variety of issues in these programs keeps me and my staff on our toes. It is never dull around here, and the moment you think all is under control, something always creeps up – and that keeps my job fairly interesting. All of us in Practice Assessment and Enhancement live by the motto "change is the new norm." We are always watching out for opportunities to be proactive and anticipate change to optimize our effectiveness.

With multiple College initiatives currently underway, such as peer redesign and recommendations from Health Quality Ontario to merge the Out-of-Hospital Premises Inspection Program and Independent Health Facilities Program into a single oversight framework, there will always be something new to learn and do.

What do you enjoy most about your role?
One of my greatest joys as a College staff member is being part of the medical regulatory process. It's rewarding to contribute meaningfully to the development of processes and tools that ultimately benefit public protection and the medical community.

Working at the College these past three years has confirmed my belief that Ontario has the best doctors in the world.

How do you and your team recharge?
As the decision writers (DWs) said in the last newsletter, we in Committee Support rely (heavily) on caffeine and sugar to recharge and boost our energy levels throughout the day. To our delight, the DWs recently received a caffeine-loaded care package from a generous "mystery donor." Whoever you are: Thank You!

What do you do for fun when you’re not working?
I cherish spending time with family and friends. My husband and I love to travel (we just returned from St. Maarten) and are already planning our next getaway.

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A “Thank You” from the Decision Writers

In the last edition of Assessor News, we profiled the Decision Writers (DWs) who confessed to having quite the sweet tooth. The DWs were thrilled when, soon after publication, an anonymous reader sent them a gift box loaded with treats. Here, they express their gratitude:

Dear Mystery “CPSO Assessor/Member” Starbucks Box Sender:

Thank you for the delicious assortment of Starbucks treats. It was very generous and thoughtful of you. It definitely put a smile on our faces and we enjoyed sharing it with our colleagues. You gave us the fuel we need to continue doing the work we do!

We are feeling the chocolate love,
The Decision Writers

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For more information or help with any of the above items contact Claudia Frisch or 416-967-2600 ext 586.

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