Quality Assessment

In diagnostic facilities: radiology; ultrasound; magnetic resonance imaging; computed tomography; nuclear medicine; positron emission tomography (PET), pulmonary function studies; and sleep medicine.

In ambulatory care facilities: surgical, therapeutic and diagnostic procedures which include dialysis, abortion, laser dermotologic surgery and ophthalmic, vascular, plastic, endoscopy and gynaecologic surgery.

How is a facility chosen for assessment?

The Director of the Independent Health Facilities program at the Ministry of Health and Long-Term Care (the “Ministry”) may request the College to perform an assessment “where the Director consider[s] it necessary or advisable.”

On an annual basis, the Ministry selects facilities to be assessed by the College. It is the mandate of the Ministry to ask the College to assess every IHF in Ontario on an ongoing basis, at least once during each facility’s three-five year licensing period.

The assessment of each facility is based on adherence to guidelines, called Clinical Practice Parameters and Facility Standards, which have been developed for services offered in an IHF. In the absence of specific guidelines, adherence to the current generally accepted medical standard of practice is assessed.

Who conducts the assessment?

The IHF staff selects an assessment team. The team is composed of a specialty-specific peer physician, and a technologist or nurse depending on whether the assessment is of a diagnostic and/or an ambulatory/surgical facility.

The IHF staff notifies the facility that the Ministry has requested the assessment and asks that the facility arrange with the assessment team a mutually convenient time for the assessment to occur. A pre-visit questionnaire is also sent to the facility to complete and return to the assessor prior to the assessment.

The assessment team meets with the facility’s owner/operator, quality advisor and other relevant staff members, and the following information is available for review:

  • Quality advisor’s agreement with the facility;
  • Policies and procedures manual;
  • Preventive maintenance, equipment and supply records;
  • Staff qualifications and appropriate attendance at CPD activities;
  • Patient procedures being performed for which the facility is licensed;
  • Patient requisitions, films/charts and reports;
  • Requesting and reporting mechanisms for diagnostic procedures; and
  • Quality management activities.


  1. The assessors may request copies of some documentation to take with them.
  2. The Ministry may ask the College to conduct quality assessments and inspections on IHFs without advance notice where there is a follow-up assessment/inspection or an assessment arising from a complaint.

What happens after the on-site assessment is completed?

The assessment team prepares a report outlining all findings and submits it to the College. This report specifies whether the facility is meeting or is in breach of the Clinical Practice Parameters and Facility Standards or current standards of practice. Where a facility is in breach of current standards, the report will also indicate how the facility can improve to meet the Clinical Practice Parameters and Facility Standards for that specialty.

The assessment report is forwarded to the IHF in order for the facility to develop a written plan of action that will address any breaches of the standards and/or generally accepted medical standards of practice. The facility is provided 14 days to provide their response back to the College.

All assessment reports are sent to a specialty-specific facility review panels. The role of the panel is to provide advice to the Director, IHF on whether the facility based on their response to the recommendation is now in compliance with the relevant Clinical Practice Parameters and Facility Standards. The panel can also recommend any follow-up assessment to the Director if warranted.

The College Registrar sends the assessment report, FRP findings to the IHF Director. The IHF Director sends the assessment report, FRP findings and Ministry decision regarding licensing to the facility.


Reference:   http://www.cpso.on.ca/Member-Information/Independent-Health-Facilities