PPEP assessments

Quality improvement approach

All registrants strive to provide the highest quality care to their patients; nevertheless, it's always possible to improve quality.

A quality improvement approach does not remove the need for quality assurance. Quality assurance establishes that a registrant’s performance meets a standard that ensures patient safety. Quality improvement is a framework to systematically enhance registrant performance in providing quality care. Together, quality improvement and quality assurance lead to safe, effective health care. 

Medical device reprocessing assessment

Medical device reprocessing assessments support, educate and assess community-based registrants who reprocess reusable semi-critical and or/critical medical devices on-site or off-site.

The goal of these assessments is to ensure registrants meet expected standards of practice and promote safe patient care. Assessments are based on the best practice requirements and recommendations established by the Ministry of Health for standard reprocessing of reusable medical devices.

Registrants and clinic staff proficient in the science of medical device reprocessing, monitoring, and documentation are critical in safeguarding the quality and lifespan of valuable medical equipment.

Assessment process

Medical device reprocessing assessments apply to registrants who practise in community-based clinics. This includes:

  • a solo office
  • multi-registrant clinics
    • the medical director is responsible for participating in the assessment
  • long-term and short-term locums

Medical device reprocessing assessments do not apply to

  • clinics or outpatient clinics that are under the direct jurisdiction of a health authority or hospital, and where reprocessing practices are monitored and evaluated by the health authority
  • clinics accredited by the Non-Hospital Medical and Surgical Facilities Accreditation Program, where reprocessing practices are assessed by that program

Participants may be selected through:

  • the annual licence renewal form
  • a peer assessor referral
  • an office assessment referral

Participants are required to complete the pre-assessment questionnaire. The questionnaire helps identify the deficiencies related to the reuse and reprocessing of medical devices in the office.

If reprocessing deficiencies are identified, recommendations for improvement are provided to the participant in an action plan—this includes guidance on how to correct deficiencies.

Participants must correct deficiencies identified in the action plan and return it for review. The assessors will review the submitted action plan and schedule a final assessment.

The time allotted to correct a deficiency depends on the level of risk. High-risk deficiencies that require immediate attention may require the office to cease reprocessing immediately until the matter is corrected. During this time, the participant may be required to obtain disposable devices in order to continue performing procedures.

Current medical device reprocessing standards state that the reprocessing of reusable medical devices must occur in a dedicated physical space. In smaller clinical offices that may not have dedicated space, reprocessing can take place in a dual-purpose or multi-purpose room with some requirements. For example, a patient exam room is acceptable provided no patients are present when the steps of reprocessing occur; however, the staff kitchen and washroom are not appropriate areas for reprocessing due to the potential for cross-contamination.

A medical device reprocessing assessor conducts the site assessment, which can take place at the office or remotely. The site assessment allows the assessor to gather detailed information on the physical set-up for reprocessing, sterile storage practices, and sterilizer function. Clinic staff are encouraged to ask questions during these site assessments.

The site assessment may identify further deficiencies and requirements for improvement that must be addressed by the participant. A completed copy of the report is returned to the College once those deficiencies are resolved. This is the final step of the assessment process.  

The College does not close clinics based on reprocessing deficiencies.

PPEP evaluation and development

Program evaluation provides information on the effectiveness, efficiency, and impact of a program, enabling informed decision-making and continuous improvement.

Learn more about the approach and feedback surveys