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. 

Peer assessment

Registrants may be selected to participate in a peer assessment specific to their specialty.

A multi-component approach

Through the multiple components of the program, including chart review, multi-source feedback tools, prescribing data, and examining practice information, the PPEP provides feedback related to a participant’s professional performance on the following areas:

  • clinical practice 
  • prescribing of controlled medication
  • feedback from colleagues, non-registrant co-workers, and patients

Through this multi-component approach, the PPEP provides external evaluation of clinical practice and helps identify unperceived needs. Program feedback and educational supports are provided to help registrants meet appropriate and current standards of practice throughout their professional lives.

Assessment process

Registrants selected to participate in an assessment receive an email to complete a pre-assessment questionnaire. 

Information provided on the questionnaire

  • allows staff to determine whether a registrant is eligible to proceed with the assessment process, and
  • provides the assessor with an initial understanding of the registrant’s work environment and scope of practice.

Selected participants begin the assessment process with the multi-source feedback component (MCC 360) that is administered by the Medical Council of Canada (MCC). The MCC contacts the participant directly with detailed instructions about the process.

The participant must complete a self-assessment. Meanwhile, the MCC surveys the following people:

  • the participant’s medical colleagues
  • the participant’s non-physician co-workers
  • the participant’s patients

Together, the surveys provide a 360-degree perspective of the participant’s practice. All responses are anonymized, collated, and analyzed to produce a multi-source feedback report.

Sample MSF report

MSF reflection tool

An assessor is assigned once the MSF component is completed. Every effort is made to match the assessor’s scope of practice and experience with that of the participant.

Assessors use the BC Assessment Tool (BCAT) which provides structure for the participant’s assessment report and evaluation criteria. The framework consists of eight assessment domains organized in the SOAP format (subjective, objective, assessment and plan).

BCAT Assessment Framework and Scoring Rubric for dermatology

BCAT Assessment Framework and Scoring Rubric for family practice

BCAT Assessment Framework and Scoring Rubric for internal medicine

BCAT Assessment Framework and Scoring Rubric for pediatrics

BCAT Assessment Framework and Scoring Rubric for psychiatry

An assessment package is sent to the participant.

The package includes:

  • instructions for selecting 10 patient records
  • a copy of the assessment report template
  • the participant's prescribing profile report
  • the participant’s multi-source feedback report and a multi-source feedback reflection tool

The assessor contacts the participant to discuss and schedule the chart review and peer interview.

The chart review involves reviewing a sample of patient records or charts. Participants are strongly encouraged to review the instructions and guidelines in preparation for their assessment.

The instructions provide guidance to ensure charts are complete and meet the standards that their assessor will reference. On the assessment date, the assessor also randomly selects and reviews additional records.

Instructions for dermatology

Instructions for family practice

Instructions for internal medicine

Instructions for pediatrics

Instructions for psychiatry

Included in the assessment package is the participant's prescribing profile. It is a report that lists narcotics and benzodiazepines that were prescribed in the most recent three-month period. 

The intent is not to facilitate a prescribing-focused review. The aim is to guide the chart review and allow the assessor to address concerns regarding:

  • large dispenses
  • high doses
  • co-prescribing
  • lack of pharmacovigilance

If no narcotics and benzodiazepines were prescribed during the last three- to six-month period, the report is not included in the assessment package.

The assessor schedules a one-hour interview with the participant when the multi-components are complete. The purpose of the interview is for the participant to provide context regarding their practice. 

The peer interview is an opportunity for both the assessor and participant to:

  • discuss questions or concerns
  • clarify chart review issues
  • review the registrant prescription profile
  • review MSF report and MSF reflection tool
  • discuss opportunities for practice improvements and continuing professional development

The assessor is also trained to use a facilitated feedback (R2C2 model) to conduct the feedback session. 

The assessor submits the participant’s practice assessment report to the PPEP when the assessment is complete.

A PPEP medical advisor reviews the assessment report and identifies opportunities for improvement.

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