Reducing risk to patients through effective compliance monitoring

As part of its public protection mandate, the College monitors all registrants who have conditions on their practice. At the core of this function is the need to mitigate the risk of non-compliance. The expectation is that registrants remain 100 per cent compliant, and the College has zero tolerance for non-compliance. Without exception, alleged breaches are referred to the Inquiry Committee.

Practice conditions arise from numerous sources, including discipline and complaints dispositions, voluntary undertakings provided by registrants, and as part of the return to work process, to name a few.

Over the past two years, the College’s investigations team has developed a robust program to ensure effective compliance monitoring, and has adopted an approach which is based on focused, file-specific assessments of all relevant factors, including risk, to determine the best monitoring approach, and the timing and frequency of monitoring inspections of registrants’ practices.

The investigations team regularly conducts unannounced office inspections of registrants subject to conditions, pursuant to section 28 of the Health Professions Act. These inspections usually include interviews with registrants and office staff, random patient chart reviews, and ensuring that appropriate signage is conspicuously displayed, if required.

In cases where registrants are required to use chaperones for sensitive exams as a condition of practice, monitoring includes chaperone vetting and approval to determine the suitability of individuals to act as chaperones. Monitoring may also include receiving and reviewing weekly reports from chaperones.

Other ways that the College monitors compliance with conditions include reviews of billings and prescription profiles. If registrants are required to have monitors as a condition of practice, the College ensures that only suitable physicians are approved. Practice monitors are required to provide regular reports to the College and have an obligation to report irregularities or concerns.

The primary objective of the compliance monitoring program is to be proactive in ensuring compliance, versus reacting once a breach has occurred and is reported to the College.