Assessments conducted by PEP
Quality improvement approach
CPSBC recognizes that all licensees are dedicated to providing the highest standard of care. The pursuit of quality is a continuous process. Quality improvement focuses on a culture of reflection, learning, and continual practice improvement to strengthen patient care. Under Practice Enhancement Program (PEP), there are several assessments intended to support our licensees’ quality improvement.
Peer assessment
Peer assessment engages eligible licensees in a peer-supported assessment of their practice. The components of this assessment map onto the CanMEDS and CanMEDS FM competencies as laid out by the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada.
The goal of a peer assessment is to support continuous quality improvement and enhance individual performance by empowering licensees through meaningful, in-the-moment discussions and feedback. This process supports professional development with an emphasis on identifying coachable moments, real-time opportunities for growth and reflection. Both peer assessors and licensees consistently report that the opportunity to engage in collegial discussion focused on quality improvement and shared learning is one of the most rewarding aspects of the peer assessment process.
A multi-component approach
Through the multiple components of the assessment, including chart review, prescribing data, and examining practice information, licensees are provided with feedback related to their clinical practice to help identify unperceived needs. Educational resources are provided to help licensees apply quality improvement strategies to their practice.
Participation in a peer assessment can earn CPD credits.
Continuing professional development credits
Family physicians: This activity has been certified by the College of Family Physicians of Canada for up to 19.5 Mainpro+® Certified Assessment Activity credits.
Podiatric surgeons: This activity has been certified by the College of Family Physicians of Canada for up to 19.5 Mainpro+® Certified Assessment Activity credits. (This an acceptable CPD source. Podiatric surgeons should review the licensure policy for continuing competency requirements of podiatric surgeons for minimum/maximum category allocations)
Specialists: This activity may qualify for continuing professional development credits through the Royal College of Physicians and Surgeons of Canada’s Maintenance of Certification (MOC) Program.
Assessment process
Licensees selected to participate in an assessment will receive an email to complete a pre-assessment questionnaire.
Information provided on the questionnaire:
- allows staff to determine whether a licensee is eligible to proceed with the assessment process, and
- provides the assessor with an initial understanding of the licensee’s work environment and scope of practice.
Every effort is made to match the peer assessor’s scope of practice and experience with that of the licensee.
Peer assessors use the BC Assessment Tool (BCAT), which provides structure for the licensee's assessment report and evaluation criteria. The framework consists of eight assessment domains organized in a SOAP-like 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
An assessment package is sent to the licensee.
The package includes:
- instructions for selecting 10 patient records
- a copy of the assessment report template
- the licensee’s prescribing profile report
- the licensee’s multi-source feedback report and a multi-source feedback reflection tool (if applicable)
The chart review involves reviewing a sample of patient records or charts by an experienced peer assessor. A review of records allows the peer assessor to develop a picture of the licensee's quality of practice and approach to patient care. Licensees 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 peer assessor will reference. On the assessment date, the assessor also randomly selects and reviews additional records.
Instructions for family practice
The licensee’s prescribing profile is included in the assessment package. The report lists narcotics and benzodiazepines 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 peer 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 peer assessor schedules a one-hour interview with the licensee when all components are complete. The peer interview offers a valuable opportunity for the licensee and the peer assessor to engage in a thoughtful, two-way conversation about the assessment findings. This peer interview is designed to foster reflection, share insights, and identify coachable moments that promote continuous quality improvement in a supportive and collegial environment.
The peer assessor conducts the peer interview with these key areas in mind:
- understanding the licensee's practice context and giving an opportunity to bring up issues, concerns, or questions
- clarifying any issues which may have arisen during the patient chart review
- review the licensee’s prescription profile and MCC 360 report (if applicable)
- gathering further information which cannot be accessed through the review of the patient charts
- highlighting opportunities for practice improvement, including continuing professional development and coaching to facilitate change
Peer assessors are trained to use a facilitated feedback (R2C2 model) to conduct the feedback session. Over the years, survey responses from licensees have consistently indicated the peer interview as one of the most valuable components of the program.
Improving after a peer assessment
PEP evaluation and development
Program evaluation provides information on the effectiveness, efficiency, and impact of a program, enabling informed decision-making and continuous improvement.