What happens after a peer assessment

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.

Performance review and action plan (PRAP) report

When a participant receives their PRAP, they are provided with instruction on how to complete a fillable action plan template. This template can be used as part of the assessment follow-up or independently. It is intended as a continuous quality-improvement tool for all registrants.

Download template


In some cases, returning a completed action plan is required as a follow up activity to the assessment. The participant is asked to

  • identify areas for improvement as noted in their PRAP report,
  • identify the steps they will take to make those improvements, and
  • provide implementation dates for these actions.

This gives us an idea of the participant’s understanding of the improvements needed, and their plan to make those changes.

A medical advisor reviews and provides feedback on the plan to ensure the participant is on the right path to making improvements. These improvements should then be reflected in their charts and lead to a successful chart submission.

Use the RISE model criteria to assess the quality of the action plan

  1. Relevant action items
    • Does the plan the address the areas for improvement noted in report?
    • Completeness: Are the areas for improvement noted in the PRAP included in the plan? Are the planned changes sufficient for successful improvement?
    • Clarity: Is it apparent what will be done and who will do what by when, to bring about change?
  2. Insight into deficiencies
    • Goals are concrete but not superficial.
    • Plans reflect thoughtful consideration of the improvement areas and how to address them.
  3. SMART goals
    • Specific: Describe exactly the action that needs to be done.
    • Measurable: Formulate the action in a way that it can be checked (measured) whether it has been carried out.
    • Achievable/attainable: How can I attain this goal?
    • Realistic: Formulate a realistic action. An action which is not realistic will never be carried out. Resources needed are realistically available.
    • Time-bound: Deadline of the action.
  4. Engagement
    • The action items are already in motion, rather than hypothetical.
    • Activities to help the physician hold themselves accountable:
      • identify learning partners or communities of practice
      • how progress will be tracked towards the goals outlined in the plan (i.e. how will the physician know if they have been achieved)?

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