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College Board prioritizes enhanced office assessment program for 2015

You may recall news coverage last November about an Abbotsford acupuncturist whose licence was suspended due to inadequate infection prevention practices, and concerns about transmission of blood-borne pathogens. The College of Traditional Chinese Medicine Practitioners and Acupuncturists took swift action and suspended the acupuncturist for a period of time while an investigation was conducted. The acupuncturist has since returned to work with strict requirements to comply with the college’s practice standards.

This disturbing story was especially relevant to regulators of health professionals who work in office-based settings, highlighting the fact that rigorous standards on their own don’t protect the public. While health professionals have a duty to be aware of and compliant with practice standards, it is the regulator’s job to develop effective standards and implement inspection processes to ensure they are being followed. 

Since 1981, this College has been conducting office inspections as an integral part of its peer assessment program, now known as the Physician Practice Enhancement Program (PPEP). The office inspection involves peer assessors conducting on-site reviews of the operational management of a physician's medical practice, such as how medical records are stored, and what protocols exist to protect patient privacy and confidentiality. Recognizing that standards inevitably evolve over time to align with new technologies, current best practices, and international quality standards, this College, in collaboration with the College of Physicians and Surgeons of Alberta, is enhancing the office inspection component of PPEP in 2015, including the development of new standards. The decision to work with the Alberta college to augment the office inspection program is in keeping with the Board’s strategic priority to enhance and expand our quality assurance activities to ensure physicians remain competent throughout their careers.

The enhanced office inspection program will focus on areas such as emergency preparedness, hand hygiene, reprocessing of instruments, infection prevention and control, and office policies and procedure (e.g. the requirement to ensure patients can access care after office hours). The assessors who conduct the inspections will be trained in occupational health and safety protocols, and will provide education and resources to staff in real time during the inspection. Utilizing the tracer methodology to analyze the office’s practices, assessors will determine whether or not medical office staff is aware of the standards and prepared to handle any event that may affect patient safety.

With the enhanced office inspection program, the role of the medical director will become even more important in terms of communicating with staff, and ensuring that any deficiencies identified during the inspection are addressed. Medical directors will be advised of these expectations in future correspondence from the program.

Over the past four years, the Physician Practice Enhancement Program has assessed more than 2,000 physicians. In 2015, the program will begin to assess internal medicine specialists and pediatricians, many of whom work in community-based settings. For more information on the PPEP, click here.

H.M. Oetter, MD

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