Quality Assurance Regulation

Quality Assurance Regulation

Midwifery Act, 1991
Loi de 1991 sur les sages-femmes

ONTARIO REGULATION 335/12

GENERAL

Consolidation Period: From January 30, 2015 to the e-Laws currency date.

Last amendment: 17/15.

This Regulation is made in English only.

PART I
QUALITY ASSURANCE

Definitions and Program Requirements

Definitions
1. In this Part,

“assessor” means an assessor appointed under section 81 of the Health Professions Procedural Code;

“Committee” means the Quality Assurance Committee required by subsection 10 (1) of the Health Professions Procedural Code;

“practice group” means, in relation to a member, a group of one or more other members with whom the member is associated and, if the member is not associated with other members, means the member;

“program” means the quality assurance program required by section 80 of the Health Professions Procedural Code. O. Reg. 335/12, s. 1.

Application
2. This Part applies only to members who hold a certificate of registration for the general or supervised practice class. O. Reg. 335/12, s. 2.

Components and administration
3. (1) The program shall include the following components:

1. Provision of clinical information.

2. Continuing education and professional development.

3. Peer case reviews.

4. Quality of care evaluations.

5. Self-assessments.

6. Peer and practice assessments. O. Reg. 335/12, s. 3 (1).

(2) The program shall be administered by the Committee. O. Reg. 335/12, s. 3 (2).

(3) The Chair of the Committee may appoint a panel of the Committee to exercise any of the powers or carry out any of the functions of the Committee. O. Reg. 335/12, s. 3 (3).

Exemptions
4. Upon application by a member, the Committee may grant an exemption to the member from any of the requirements of the program because of illness, maternity leave or any other circumstance the Committee considers appropriate. O. Reg. 335/12, s. 4.

Provision of Clinical Information

Information re care of patients
5. (1) At the request of the Committee, a member shall provide information relating to the member’s care of patients to the College in the form and manner specified by the Committee and within the time period specified in the Committee’s request or, where no time period is specified, within 30 days after the member receives the request. O. Reg. 335/12, s. 5 (1).

(2) The Committee may request that the information referred to in subsection (1) relates to the member’s care of patients during a specified time period. O. Reg. 335/12, s. 5 (2).

(3) A member shall ensure that no patients are identified in the information provided to the College under subsection (1). O. Reg. 335/12, s. 5 (3).

Continuing Education and Professional Development

Participation and record-keeping
6. (1) A member shall participate in continuing education and professional development activities for the purpose of maintaining and enhancing the member’s knowledge, skill and judgment. O. Reg. 335/12, s. 6 (1).

(2) Continuing education and professional development activities shall, among other things, address the following topics:

1. Standards of practice.

2. Changes in practice environment.

3. Advances in technology.

4. Changes made to entry to practice competencies. O. Reg. 335/12, s. 6 (2).

(3) A member shall maintain an annual record of the member’s participation in continuing education and professional development activities and, each year, shall submit the record to the College in the manner specified by the Committee. O. Reg. 335/12, s. 6 (3).

(4) A member shall retain the annual record for at least five years from the date the member submits the record to the College. O. Reg. 335/12, s. 6 (4).

(5) The annual record shall contain details about the member’s learning needs as identified by the member and shall list each mandatory continuing education and professional development activity that the member participates in that year, including the content, date, duration, location and, if applicable, the name of the sponsor, for each activity. O. Reg. 335/12, s. 6 (5).

(6) The Committee may specify the form and manner in which the annual record must be kept and may specify any additional content that shall be included in the record. O. Reg. 335/12, s. 6 (6).

Peer Case Reviews

Participation and record-keeping
7. (1) The purpose of a peer case review is for members to meet and discuss the clinical care of patients by studying individual patient cases. O. Reg. 335/12, s. 7 (1).

(2) A member shall participate in at least six peer case reviews in every 12-month period commencing on a date to be specified by the Committee. O. Reg. 335/12, s. 7 (2).

(3) A peer case review shall be conducted by a group of at least four members belonging to at least two different practice groups. O. Reg. 335/12, s. 7 (3).

(4) If all of the members in a peer case review group agree, any number of students who are enrolled in a midwifery education program at an Ontario institution may participate in the review. O. Reg. 335/12, s. 7 (4).

(5) A peer case review shall be conducted in the form and manner approved by the Committee and shall include,

(a) presentation of a case history, including how the case was managed, by one of the members participating in the review;

(b) discussion of the application of College regulations, by-laws, standards, guidelines and policies to the case presented; and

(c) observations and feedback from the group members about how the case presented was managed. O. Reg. 335/12, s. 7 (5).

(6) A member of a peer case review group shall not disclose information obtained during a peer case review that relates to any other member unless the disclosure is required by an Act of the Legislature or an Act of Parliament or unless the member to whom the information relates consents to the disclosure. O. Reg. 335/12, s. 7 (6).

(7) A member shall maintain an annual peer case review record of the member’s participation in six peer case reviews. O. Reg. 335/12, s. 7 (7).

(8) An annual peer case review record shall include,

(a) the names of the members who participated in each review;

(b) the date on which each review took place;

(c) the duration of each review; and

(d) the number of cases reviewed during each review. O. Reg. 335/12, s. 7 (8).

(9) Each year, a member shall submit their annual peer case review record to the College in the manner specified by the Committee. O. Reg. 335/12, s. 7 (9).

(10) A member shall retain an annual peer case review record for at least five years from the date the member submits the record to the College. O. Reg. 335/12, s. 7 (10).

Quality of Care Evaluations

Evaluation form and record-keeping
8. (1) A member shall, within six months after a patient is discharged from the member’s care, provide to the patient a quality of care evaluation form and shall request that the patient complete the form and return it to the member’s practice group. O. Reg. 335/12, s. 8 (1).

(2) An evaluation form shall not identify the patient completing the form unless the patient identifies herself. O. Reg. 335/12, s. 8 (2).

(3) A member shall keep a record of whether the member takes any action in response to a patient’s evaluation and, each year, shall submit the record to the College in the manner specified by the Committee. O. Reg. 335/12, s. 8 (3).

(4) The Committee may require that the patient’s evaluation and the record of whether the member takes any action be in forms approved by the Committee. O. Reg. 335/12, s. 8 (4).

(5) A member shall retain,

(a) a completed evaluation form for at least five years from the date the form is returned to the member’s practice group; and

(b) the record of whether the member takes any action in response to a patient evaluation for at least five years from the date the member submits the record to the College. O. Reg. 335/12, s. 8 (5).

Self-Assessments

Questionnaire and declaration
9. (1) At the request of the Committee, a member shall,

(a) complete a self-assessment questionnaire in the form and manner approved by the Committee;

(b) sign a declaration in the form and manner specified by the Committee stating that the member has completed the questionnaire; and

(c) submit the declaration to the College within the time period specified in the request or, where no time period is specified, within 30 days after the member receives the request. O. Reg. 335/12, s. 9 (1).

(2) At the request of the Committee, a member shall submit a completed self-assessment questionnaire to the College within the time period specified in the request or, where no time period is specified, within 30 days after the member receives the request. O. Reg. 335/12, s. 9 (2).

(3) A member shall retain a completed self-assessment questionnaire for at least 10 years from the date the member submits the declaration to the College. O. Reg. 335/12, s. 9 (3).

Peer and Practice Assessments

Selection of members
10. (1) Each year, the Committee shall select members to undergo peer and practice assessments in order to assess whether the members’ knowledge, skill and judgment are satisfactory. O. Reg. 335/12, s. 10 (1).

(2) The Committee may select a member to undergo a peer and practice assessment,

(a) through a process of random selection;

(b) on the basis of criteria specified by the Committee and published on the College’s website at least three months before a member is selected on the basis of that criteria; or

(c) if a request is made to review the member’s information, records, forms, assessments or questionnaires under this Part and the Committee or an assessor is of the opinion that the member has not provided satisfactory documentation in accordance with the request. O. Reg. 335/12, s. 10 (2).

Components of assessment
11. A peer and practice assessment shall be conducted by an assessor and may include,

(a) an inspection of the forms and other documents used in the member’s practice;

(b) an inspection of the member’s records of the care of patients;

(c) an assessment of any information respecting the member’s care of patients;

(d) an interview with the member;

(e) an inspection of the premises where the member practises; and

(f) an examination of the member’s birth kit. O. Reg. 335/12, s. 11.

Written report
12. (1) An assessor shall, within the time period specified by the Committee, provide to the College a written report of the assessment. O. Reg. 335/12, s. 12 (1).

(2) The Committee shall provide to the member a copy of the assessor’s report and notice of the member’s right to make written submissions to the Committee within 14 days after the member receives the report and the notice. O. Reg. 335/12, s. 12 (2).

Remedial action
13. After considering the assessor’s report and any submissions made by the member, the Committee may take any action listed in subsection 80.2 (1) of the Health Professions Procedural Code. O. Reg. 335/12, s. 13.

PART II
NOTICE OF OPEN MEETINGS AND HEARINGS

Council Meetings

Notice requirement
14. (1) The Registrar shall ensure that notice of every council meeting that is required to be open to the public under the Act is given in accordance with this section. O. Reg. 335/12, s. 14 (1).

(2) The notice shall be published no less than 14 days before the date of the meeting in a daily newspaper of general circulation throughout Ontario. O. Reg. 335/12, s. 14 (2).

(3) The notice shall be in English and French. O. Reg. 335/12, s. 14 (3).

(4) The notice shall include the intended date, time and place of the meeting and a statement of the purpose of the meeting. O. Reg. 335/12, s. 14 (4).

(5) The Registrar shall give a copy of the notice to every person who requests it. O. Reg. 335/12, s. 14 (5).

Discipline Committee Hearings

Provision of information
15. (1) The Registrar shall ensure that information concerning a hearing by a panel of the Discipline Committee respecting allegations of professional misconduct or incompetence by a member is given to every person who requests it,

(a) at least 30 days before the intended date of the hearing, if possible; or

(b) for requests made less than 30 days before the meeting, as soon as reasonably possible after the request is made. O. Reg. 335/12, s. 15 (1).

(2) The information shall be available in English and French. O. Reg. 335/12, s. 15 (2).

(3) The information shall include,

(a) the name of the member against whom the allegations have been made;

(b) the member’s principal place of practice;

(c) the intended date, time and place of the hearing; and

(d) a statement of the purpose of the hearing. O. Reg. 335/12, s. 15 (3).

PART III
INTUBATION OF A NEWBORN

Requirements for intubation beyond the larynx of a newborn
15.1 A member is authorized to perform a procedure under paragraph 10 of section 4 of the Act if the procedure is performed in accordance with the following requirements:

1. The member has the knowledge, skill and judgment to perform the procedure safely, effectively and ethically.

2. Before performing the procedure, the member determines that the newborn’s condition warrants performance of the procedure, having considered,

i. whether the procedure is necessary to preserve or restore the health of the newborn,

ii. the known risks and benefits to the newborn of performing the procedure,

iii. the predictability of the outcome of performing the procedure,

iv. the safeguards and resources available in all the circumstances to safely manage the outcome of performing the procedure, and

v. other relevant factors specific to the situation.

3. The member has successfully completed an intubation training program approved by the Council. O. Reg. 17/15, s. 1.

16. Omitted (revokes other Regulations). O. Reg. 335/12, s. 16.

17. Omitted (provides for coming into force of provisions of this Regulation). O. Reg. 335/12, s. 17.