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.
Self-directed assessment
The self-directed assessment engages eligible licensees in a light-touch, CPD-compatible program with a five-year cycle to complete three quality improvement activities. This builds on the principles of right-touch regulation and commitment to fulfill our mandate of ensuring quality care for patients in BC.
Self-directed assessments are proactive, self-driven, and encourages licensees to reflect on their own delivery of health care without a large time commitment. The goal of a self-directed assessment is to encourage self-reflection and continued improvement and learning throughout a career in medicine.
Synergy with continuing professional development requirements
All licensees must comply with continuing professional development (CPD) requirements. Activities that licensees currently undertake for CPD may also align with one or all three of the core components of the self-directed assessment. This would satisfy the requirements for both.
Email sda@cpsbc.ca to confirm.
Continuing professional development credits
The self-directed assessment uses the College of Family Physicians of Canada's Professional Learning Plan (CFPC PLP) peer-supported pathway to guide quality improvement activities.
It is a one-credit-per-hour assessment activity certified by the CFPC for 20 Mainpro+® certified credits.
Self-directed assessments will use the Royal College of Physicians and Surgeons’ Practice Improvement Roadmap under the Maintenance of Certification (MOC) Program. This Practice Improvement Roadmap is designed to guide both individual and team-based learning, reflection, and continuous practice improvement. It draws on established quality improvement principles and is adapted from The Ottawa Hospital Innovation Framework™ (© The Ottawa Hospital, 2022).
Complete 3 core component activities and meet with a program advisor
In a self-directed assessment, licensees guide their own professional development goals within a quality improvement framework. Using a quality improvement approach, licensees select quality improvement activities that fall into the three core components, complete those activities, and reflect on their outcomes.
Licensees have five years to complete three activities plus a facilitated feedback session with a program advisor.
Core components
The three core components echo the three bases of the Cambridge model (the relationship between competence and performance includes system and individual related influences) and include:
Focus on improvements to clinical care, using the licensee's own patient demographics to identify areas for improvement that may support effective clinical care (e.g. using EMR data to determine the number of patients in your panel with type 2 diabetes).
Identify areas for improvement in the licensee's practice environment, chart documentation, or clinic operations (e.g. improve office flow for patient visits, improve patient documentation by using voice recognition software).
Reflect on the licensee's professional life, work-life balance, communications and approach to team-based care (e.g. seek formal feedback from patients, colleagues, and co-workers).
Facilitated feedback discussion
This conversation is led by a program advisor. It is a progress check-in and a collaborative coaching discussion to review the status of the licensee's quality improvement activities, examine barriers and explore potential issues. This session helps refine areas for improvement and promotes a culture of continuous practice enhancement.
The check-in is scheduled around the mid-point of the five-year cycle.
Email sda@cpsbc.ca to request an earlier session.
Program advisors
Program advisors are licensed BC physicians, surgeons, and podiatric surgeons who have successfully completed peer assessments in their own practice. Their participation in the assessments help them assist others who are starting on their self-directed assessment journeys.
Program advisors hold a full licence, remain clinically current, and are in good standing with CPSBC. They have specialized assessment training and bring diverse practice backgrounds from across the province.
Interested in becoming a program advisor?
Email pep@cpsbc.ca for more information.
How it works
Licensees selected to participate in an assessment will receive an email to complete a pre-assessment questionnaire (PAQ).
The PAQ confirms eligibility for SDA and provides background information for the program.
For each of the three core components, licensees can complete:
- the CFPC professional learning plan peer-supported pathway,
- the RCPSC Practice Improvement Roadmap,
- the UBC professional learning plan activity,
- FPSC's Practice Support Program, or
- other quality improvement programs.
Once they have completed a quality improvement plan and associated activity, they submit their certificate of completion and complete a self-directed activity form to describe the activity completed.
At the mid-point of the five-year cycle or when two core components are fulfilled and documents are submitted, program staff will contact the licensee to schedule the facilitated feedback session with a program advisor.
A final summary report is sent to the licensee once all components and activities are completed.
Example of a participant’s core component activities
Activities that licensees already undertake for continuing professional development may often align with the core components of the self-directed assessment.
Here is an example of a pathway:
Dr. A is new to practice in BC and would like to understand how they can approach cultural safety and humility in their medical practice.
Clinical support: Dr. A wants to understand the interaction between traditional healing remedies and Western medicine approaches to the management of diabetes, and be able to advise her Indigenous patients respectfully on combining traditional and Western medicine approaches. For their QI activity, they conduct a search of relevant databases, consult Divisions and other practitioners who have tackled this issue, and reach out to an Elder to advise on most common traditional remedies. They research interactions between them and the common Western medicines that may be prescribed, and summarize their findings.
Practice support: Dr. A uses their EMR functions or AI scribe to place a prompt to ask all patients if they are using any alternative/ traditional medications or remedies, and develop an EMR template that encourages the discussion and documentation of Indigenous healing remedies/ alternative/ complementary therapies.
Professional support: Dr. A seeks to build on their foundational knowledge of Indigenous issues by undertaking their own education and experiences in Indigenous history and culture in British Columbia. Dr. A seeks formal learning opportunities (e.g. courses) and experiential learning (blanket exercise, connecting with local communities) for personal and professional growth. Dr. A creates an action plan to explore how they can improve their own understanding and strengthen their ability to have deep and respectful conversations with all patients.
PEP evaluation and development
Program evaluation provides information on the effectiveness, efficiency, and impact of a program, enabling informed decision-making and continuous improvement.