A Short Guide to the Quality Assurance Program

 

Why do we have a Quality Assurance Program?

 

In the regulated health professions, quality assurance is mandatory. The Regulated Health Professions Act, 1991 dictates that we must have in place a quality assurance program in order to be self-regulated and that the program must consist of:

·         Continuing education and professional development

·         Self, peer and practice assessment

·         A mechanism for the College to monitor participation and compliance

 

Who decides the details of this program?

 

You do! Well, at least indirectly, because the Council of the College is made up of members of the profession you elect, along with members of the public appointed by the government of Ontario and academic members. The Council members look at the quality assurance regulations that are specified in the RHPA and decide how they will implement and administer them.

 

How are members selected for Self Assessment submission or Peer Assessment?

 

Each year an outside information technology company randomly selects 250 members who are requested to submit their SATs and 30 members who are to under go a Peer Assessment. It is truly the ‘luck of the draw’.

 

What is the Quality Assurance Program?

 

The Quality Assurance Program involves 4 facets. We have the Self Assessment Tool, the Continuous Learning Activity Credits (CLACs), the Peer Assessment Program and the Practice Standards.

1. Self Assessment Tool (SAT): The guide for the SAT will direct you to evaluate five Professional Practice Standards, which are:
   • Management Practice
   • Clinical Practice
   • Patient/Client Centered Practice
   • Communication
   • Professional Accountability

You are expected to complete the Self-Assessment Tool every 3 years and to review the Continuous Learning Activities every year. Members should note that CASLPO has now put everybody on the same 3-year cycle, which is currently January 2008 to December 2010. The following cycle will be January 2011 to December 2013. If you happen to be randomly selected to submit your SAT, CASLPO will review the SATs to collect aggregate data and determine if it is complete. However, they will not be individually evaluated. It is designed to be a tool for self-assessment and as such not subjected to evaluation by anybody other than you. If you are randomly selected to submit your SAT, you do not need to submit your evidence of compliance. The random selection is completed by an outside information technology company.

 

2.    Continuous Learning Activity Credits (CLACs): This is your continuing education and professional development. You are to accumulate 45 credits over 3 years. You need to first identify three or more Learning Goals that relate to your self-assessment and your professional practice. These goals are generally broadly stated goals that include a rationale for participating in continuous learning. Learning goals can be related to a specific indicator within a standard (see the 5 standards listed above), they can be unrelated to the indicators or they can be added as a result of a learning opportunity that arises. To further assist members in ensuring that their Learning Goals meet the criteria, CASLPO has developed a Learning Goal template which provides members with an option for formulating learning goals. Use of the template is not required but it may support members as they try to make sure that all the criteria for Learning Goals are met.

 

The standard wording to refer to the	The standard wording to state the purpose of
learning activity would be one of the	learning would be one of the following:
following:
To learn more about ..... the information to be	In order to ..... a statement relating the learning
learned would then be defined.	to the practice would then be added.
To acquire knowledge of. .... the information to	To provide ..... a statement relating the learning to
be learned would then be defined.	the practice would then be added.
To further knowledge of. .... the information to	To ensure ..... a statement relating the learning to
be learned would then be defined.	the practice would then be added.

 

Your learning activities will then be categorized according to these Learning Goals. Not all activities qualify as a credit and there are restrictions on the number of CLACs that can be claimed for some activities so consult the Self Assessment Guide.

 

3. Peer Assessment Program: Great efforts are made to ensure that this is a positive learning process. The large majority of the membership is found to be compliant in all areas. In the instances where partial or non-compliance is identified, the Quality Assurance Committee will request further information and/or action. However, our Peer Assessors are practicing clinicians and come to the process with a strong sense of what is practical and reasonable. They may be your best ‘mentor’.

 

There are 4 phases to this process:

·         You  submit your SAT and your evidence of compliance

·         You are then paired up with a Peer Assessor (based on your population of patient/clients, location, etc.), who reviews your evidence and arranges a site visit. The member has the opportunity to veto one peer assessor, if they so choose.

·         A site visit usually takes approximately ¾ of a day, and involves a file review and discussion around practice issues as well as a review of any onsite evidence.

·         The Peer Assessor then submits a report on the details of your self-assessment, your evidence of compliance and the information discussed at the site visit. You have the opportunity to read this report and respond prior to when the Quality Assurance Committee reviews it. The Committee looks at all the information gathered, including your response if you had one, and determines if all is going well with your practice, or if you would benefit from some sort of follow-up actions. The Committee meets approximately six times per year so feedback to the member may take up to 4 months.

 

4. Practice Standards:  These are important documents that guide your practice and contribute to ensuring a quality practice. As such, each member must take the time to read, understand and follow them. They include (and can be found at www.caslpo.com):

 

·         Preferred Practice Guidelines (PPG’s) and Practice Standards and Guidelines (PSG’s)

·         Position Statements

·         Code of Ethics

·         Sexual Abuse Prevention Plan

·         Infection Control

·         Regulated Health Professions Act

·         Audiology and Speech-Language Pathology Act

·         Health Care Consent Act

·         Personal Health Information Act

 

In addition there is a wealth of practical information available in CASLPO Today.  Listed below are all the articles since 2007 that relate to the Quality Assurance Program and an up to date listing can always be found at www.caslpo.com.

 

 

 

If you have any questions or comments, please contact Carol Bock, Deputy Registrar at (416) 975-5347 x227.