Standards

Creating a Culture of Safety and Quality

1. Medical Directors must foster a culture of safety and quality within the OHP.
2. Medical Directors must ensure that the OHP maintains a Quality Assurance program and that it undertakes initiatives to improve the quality of care within the premises.
3. Medical Directors must ensure the OHP has a Quality Assurance (QA) committee for the purpose of creating processes to establish standards, monitor activity, and improve performance to ensure appropriate volume and scope of services provided.
4. Medical Directors must:
   1. hold, at a minimum, two QA committee meetings at each OHP site per year, that address quality issues (e.g., infection control) and review policies and procedures, challenging cases, near misses¹, adverse events and protocols as appropriate to minimize adverse events;
   2. ensure meetings are attended by all staff providing patient care where possible, and that all staff who are unable to attend are updated on the meeting discussions and outcomes;
   3. ensure all meetings, including the staff who were in attendance, are documented and that the documentation is available to CPSO upon request.
5. Medical Directors must ensure that members of staff undertake continuing education relevant to their practice in the OHP, in accordance with applicable regulatory requirements, to maintain clinical competency and knowledge of best practices.

Monitoring Quality of Care

6. Medical Directors must ensure there is a documented process in place to regularly monitor the quality of care provided to patients through activities, including the following:
   1. review of all staff performance (i.e., both medical and non-medical staff);
   2. review of individual physician care to assess:
      • patient and procedure selection are appropriate
      • patient outcomes are appropriate
      • adverse events;
   3. review a selection of individual patient records to assess completeness and accuracy of entries by all staff²;
   4. review of activity related to cleaning, sterilization, maintenance, and storage of equipment;
   5. documentation of the numbers of procedures performed (i.e., any significant annual increase/decrease (>50% of the last reported assessment)).

Endnotes

^1. Near miss incident is defined in CPSO’s Disclosure of Harm policy as an incident with the potential for harm that did not reach the patient due to timely intervention or good fortune (also known as a “close call”). For specific examples, please see the Advice to the Profession: Disclosure of Harm.

^2. In an OHP where the Medical Director is the only practising physician, the process for reviewing records will need to include a review of that physician’s patient records by a peer.