QA Regulations
Regulated Health Professions Act, 1991
Quality Assurance Committee
79.1 Repealed: 2007, c. 10, Sched. M, s. 57.
Quality assurance program required
80. The Council shall make regulations under clause 95 (1) (r) prescribing a quality assurance program. 1991, c. 18, Sched. 2, s. 80; 2000, c. 26, Sched. H, s. 3 (1).
Minimum requirements for quality assurance program
80.1 A quality assurance program prescribed under section 80 shall include,
- (a) continuing education or professional development designed to,
- (i) promote continuing competence and continuing quality improvement among the members,
- (i.1) promote interprofessional collaboration,
- (ii) address changes in practice environments, and
(iii) incorporate standards of practice, advances in technology, changes made to entry to practice competencies and other relevant issues in the discretion of the Council;
- (b) self, peer and practice assessments; and
(c) a mechanism for the College to monitor members’ participation in, and compliance with, the quality assurance program. 2007, c. 10, Sched. M, s. 58.
80.2 (1) The Quality Assurance Committee may do only one or more of the following:
- 1. Require individual members whose knowledge, skill and judgment have been assessed under section 82 and found to be unsatisfactory to participate in specified continuing education or remediation programs.
2. Direct the Registrar to impose terms, conditions or limitations for a specified period to be determined by the Committee on the certificate of registration of a member,
- i. whose knowledge, skill and judgment have been assessed or reassessed under section 82 and have been found to be unsatisfactory, or
ii. who has been directed to participate in specified continuing education or remediation programs as required by the Committee under paragraph 1 and has not completed those programs successfully.
4. Disclose the name of the member and allegations against the member to the Inquiries, Complaints and Reports Committee if the Quality Assurance Committee is of the opinion that the member may have committed an act of professional misconduct, or may be incompetent or incapacitated. 2007, c. 10, Sched. M, s. 58.
(2) No direction shall be given to the Registrar under paragraph 2 of subsection (1) unless the member has been given notice of the Quality Assurance Committee’s intention to give direction, and at least 14 days to make written submissions to the Committee. 2007, c. 10, Sched. M, s. 58.
Assessors
81. The Quality Assurance Committee may appoint assessors for the purposes of a quality assurance program. 1991, c. 18, Sched. 2, s. 81.
Co-operation with Committee and assessors
82. (1) Every member shall co-operate with the Quality Assurance Committee and with any assessor it appoints and in particular every member shall,
- (a) permit the assessor to enter and inspect the premises where the member practises;
(b) permit the assessor to inspect the member’s records of the care of patients;
(c) give the Committee or the assessor the information in respect of the care of patients or in respect of the member’s records of the care of patients the Committee or assessor requests in the form the Committee or assessor specifies;
(d) confer with the Committee or the assessor if requested to do so by either of them; and
(e) participate in a program designed to evaluate the knowledge, skill and judgment of the member, if requested to do so by the Committee.
(2) Every person who controls premises where a member practises, other than a private dwelling, shall allow an assessor to enter and inspect the premises.
Inspection of records
(3) Every person who controls records relating to a member’s care of patients shall allow an assessor to inspect the records.
Exception
(4) Subsection (3) does not require a patient or his or her representative to allow an assessor to inspect records relating to the patient’s care.
Conflict
(5) This section applies despite any provision in any Act relating to the confidentiality of health records. 1991, c. 18, Sched. 2, s. 82.
Confidentiality of information
83. (1) Except as provided in section 80.2 and in this section, the Quality Assurance Committee and any assessor appointed by it shall not disclose, to any other committee, information that,
- (a) was given by the member; or
(b) relates to the member and was obtained under section 82. 1991, c. 18, Sched. 2, s. 83 (1); 2007, c. 10, Sched. M, s. 59 (1).
(2) Where relevant to a proceeding before a committee, information described in subsection (1) may be disclosed to that committee for the purpose of showing that the member knowingly gave false information to the Quality Assurance Committee or an assessor. 2007, c. 10, Sched. M, s. 59 (2).
(3) Repealed: 2007, c. 10, Sched. M, s. 59 (3).
Use in other Committees
(4) Information that was disclosed contrary to subsection (1) shall not be used against the member to whom it relates in a proceeding before the Discipline or Fitness to Practise Committees. 1991, c. 18, Sched. 2, s. 83 (4).
(5) Repealed: 2004, c. 3, Sched. B, s. 11 (1).
Quality assurance and other information
83.1 (1) In this section,
- “disclose” means, with respect to quality assurance information, to provide or make the information available to a person who is not,
- (a) a member of the Quality Assurance Committee,
(b) an assessor appointed by the Committee, a person engaged on its behalf such as a mentor or a person conducting an assessment program on its behalf, or
(c) a person providing administrative support to the Committee or the Registrar or the Committee’s legal counsel,
“proceeding” includes a proceeding that is within the jurisdiction of the Legislature and that is held in, before or under the rules of a court, a tribunal, a commission, a justice of the peace, a coroner, a committee of a College under the Regulated Health Professions Act, 1991, a committee of the Board under the Drugless Practitioners Act, a committee of the College under the Social Work and Social Service Work Act, 1998, an arbitrator or a mediator, but does not include any activities carried on by the Quality Assurance Committee; (“instance”)
“quality assurance information” means information that,
- (a) is collected by or prepared for the Quality Assurance Committee for the sole or primary purpose of assisting the Committee in carrying out its functions,
(b) relates solely or primarily to any activity that the Quality Assurance Committee carries on as part of its functions,
(c) is prepared by a member or on behalf of a member solely or primarily for the purpose of complying with the requirements of the prescribed quality assurance program, or
(d) is provided to the Quality Assurance Committee under subsection (3),
- (e) the name of a member and allegations that the member may have committed an act of professional misconduct, or may be incompetent or incapacitated,
(f) information that was referred to the Quality Assurance Committee from another committee of the College or the Board, or
(g) information that a regulation made under this Code specifies is not quality assurance information and that the Quality Assurance Committee receives after the day on which that regulation is made; (“renseignements sur l’assurance de la qualité”)
- (a) is examined or cross-examined for discovery, either orally or in writing,
(b) makes an affidavit, or
(c) is competent or compellable to be examined or cross-examined or to produce a document, whether under oath or not. (“témoin”) 2004, c. 3, Sched. B, s. 11 (2).
(2) In the event of a conflict between this section and a provision under any other Act, this section prevails unless it specifically provides otherwise. 2004, c. 3, Sched. B, s. 11 (2).
Disclosure to Quality Assurance Committee
(3) Despite the Personal Health Information Protection Act, 2004, a person may disclose any information to the Quality Assurance Committee for the purposes of the committee. 2004, c. 3, Sched. B, s. 11 (2).
Quality assurance information
(4) Despite the Personal Health Information Protection Act, 2004, no person shall disclose quality assurance information except as permitted by the Regulated Health Professions Act, 1991, including this Code or an Act named in Schedule 1 to that Act or regulations or by-laws made under the Regulated Health Professions Act, 1991 or under an Act named in Schedule 1 to that Act. 2004, c. 3, Sched. B, s. 11 (2).
Non-disclosure in proceeding
(5) No person shall ask a witness and no court or other body conducting a proceeding shall permit or require a witness in the proceeding to disclose quality assurance information except as permitted or required by the provisions relating to the quality assurance program. 2004, c. 3, Sched. B, s. 11 (2).
Non-admissibility of evidence
(6) Quality assurance information is not admissible in evidence in a proceeding. 2004, c. 3, Sched. B, s. 11 (2).
Non-retaliation
(7) No one shall dismiss, suspend, demote, discipline, harass or otherwise disadvantage a person by reason that the person has disclosed information to the Quality Assurance Committee under subsection (3), but a person may be disciplined for disclosing false information to the Committee. 2004, c. 3, Sched. B, s. 11 (2).
Immunity
(8) No action or other proceeding may be instituted against a person who in good faith discloses information to a Quality Assurance Committee at the request of the Committee or for the purposes of assisting the Committee in carrying out its functions. 2004, c. 3, Sched. B, s. 11 (2).
Regulations under the Pharmacy Act, 1991
PART VIII- QUALITY ASSURANCE
General
41. In this Part,
- "assessor" means an assessor appointed under section 81 of the Health Professions Procedural Code;
"Committee" means the Quality Assurance Committee. O. Reg. 98/98, s. 2.
- 1. Maintenance of a portfolio of continuous learning.
2. Maintenance of a two-part register for pharmacist members.
3. Practice review and remediation.
4. Remediation of behaviour and remarks of a sexual nature. O. Reg. 98/98, s. 2.
43. (1) A pharmacist shall maintain a portfolio of continuous learning activities in accordance with guidelines on such activities published by the College and distributed to the members.
(2) A pharmacist shall submit the portfolio to the College on request. O. Reg. 98/98, s. 2.
Two-Part Register for Pharmacists
44. (1) The part of the College's register that lists pharmacists shall have a Part A (patient care) and a Part B (no patient care). O. Reg. 451/10, s. 7.
(2) Every pharmacist shall be listed in either Part A or Part B. O. Reg. 451/10, s. 7.
45. (1) Upon being issued a certificate of registration as a pharmacist for the first time, the member shall ask to be listed in Part A or Part B of the register by completing and submitting the form provided by the Registrar. O. Reg. 451/10, s. 7.
(2) Every year at the time of paying the annual membership fee, a pharmacist shall ask for a renewal of his or her listing in Part A or Part B or for a transfer to the other Part. O. Reg. 451/10, s. 7.
(3) A member who asks for a renewal of a listing in Part A after the third anniversary of being issued a certificate of registration as a pharmacist for the first time shall not be listed in that Part unless he or she has dispensed, sold or compounded drugs, provided non-prescription drugs, health care aids and devices or information related to drug use for at least 600 hours during the preceding three years in the course of providing patient care while practising the profession in Canada. O. Reg. 451/10, s. 7.
46. (1) A pharmacist may ask for a transfer from Part A of the register to Part B or from Part B to Part A at any time. O. Reg. 451/10, s. 7.
(2) If a member listed in Part A asks for a transfer to Part B, the member shall be transferred to Part B. O. Reg. 451/10, s. 7.
(3) If a member listed in Part B asks for a transfer to Part A, the member shall be transferred to Part A if he or she,
- (a) undergoes a practice review in accordance with section 47; and
(b) satisfies the educational and practice requirements that may be specified by the Quality Assurance Committee. O. Reg. 451/10, s. 7.
(5) The member shall be given a reasonable opportunity to make written submissions to the panel before it makes a decision. O. Reg. 451/10, s. 7.
(6) A member whose request to be listed in Part A is rejected by the panel may appeal to another panel of the Quality Assurance Committee. O. Reg. 451/10, s. 7.
(7) No member of a panel that rejects a request to be listed in Part A shall sit on a panel hearing an appeal of that decision. O. Reg. 451/10, s. 7.
(8) On an appeal, the member shall be given a reasonable opportunity to make written submissions to the panel before it makes a decision. O. Reg. 451/10, s. 7.
Practice Review and Remediation
47. (1) Each year the College shall select at random the names of pharmacists required to undergo a practice review.
(2) A pharmacist listed in Part A is required to undergo a practice review if his or her name is selected at random or the member is referred to the Committee by the Complaints Committee or Executive Committee.
(3) If a pharmacist listed in Part A fails to undergo a required practice review, the Committee may transfer the pharmacist to Part B after giving him or her a reasonable opportunity to make written submissions.
(4) A pharmacist listed in Part B is required to undergo a practice review if he or she is referred to the Committee by the Complaints Committee or Executive Committee or if the pharmacist has asked to be listed in Part A under subsection 46 (3).
(5) The Committee shall appoint an assessor to conduct a practice review.
(6) The assessor shall prepare a written report on the review and submit it to the Committee.
(7) After considering the report, the Committee may decide,
- (a) that no further action is required;
(b) that the pharmacist is required to undertake the remediation specified by the Committee to correct any deficiency in his or knowledge, skills or judgment identified by the review; or
(c) that the pharmacist is to be listed in Part A where the review took place pursuant to a request to be listed in Part A.
- (a) the pharmacist has been given a report of the results of the review;
(b) the pharmacist has been given written notice of the Committee's intention to require him or her to undertake remediation;
(c) the pharmacist has been given at least 14 days from receipt of the notice to make written submissions to the Committee; and
(d) the Committee has considered any such submissions.
48. (1) If the Committee requires a pharmacist to undertake remediation under section 47 and the pharmacist either fails to do so or fails to successfully complete the remediation, the Committee may direct the Registrar to impose terms, conditions or limitations on the pharmacist's certificate of registration for a specified period not exceeding six months.
(2) If the Committee proposes to make a direction under subsection (1), it shall not do so unless,
- (a) the pharmacist has been given written notice of its intention;
(b) the pharmacist has been given at least 14 days from receipt of the notice to make written submissions to the Committee or to request an appearance before the Committee in order to make oral submissions; and
(c) the Committee has considered any such submissions.
(4) If the period specified under subsection (1) expires and the pharmacist still has not undertaken or successfully completed the remediation, the Committee may report him or her to the Executive Committee and provide it with such information as it considers appropriate, except information that may not be disclosed under section 83 of the Health Professions Procedural Code.
(5) If the Registrar imposes terms, conditions or limitations on a pharmacist's certificate of registration for a specified period pursuant to a direction given by the Committee under subsection (1), the Committee may direct the Registrar to remove the terms, conditions or limitations before the end of the specified period if the Committee is satisfied that they are no longer needed.
(6) After directing the imposition of terms, conditions or limitations on a pharmacist's certificate of registration for a specified period not exceeding six months under subsection (1), the Committee may direct the imposition of terms, conditions or limitation on the pharmacist's certificate of registration for a second specified period not exceeding six months under subsection (1) but, after having done so, the Committee shall not direct the imposition of terms, conditions or limitations on the pharmacist's certificate of registration for any further specified period.
(7) If the Committee directs a second imposition of terms, conditions or limitations on the pharmacist's certificate, subsections (2), (3), (4) and (5) apply with respect to the second imposition. O. Reg. 98/98, s. 2.
Remediation of Behaviour and Remarks of a Sexual Nature
49. (1) This section applies to matters referred to the Committee by,
- (a) a panel of the Complaints Committee under subsection 26 (3) of the Health Professions Procedural Code; and
(b) the Executive Committee under section 79.1 of the Code.
(3) The chair of the Committee shall appoint a mediator to attempt to resolve the matter.
(4) If the mediator is unable to resolve the matter within 90 days after being appointed, the mediator shall report the failure to the chair without delay and provide the chair with a written report on the mediation.
(5) The chair shall give the member complained against a copy of the mediator's report and a notice advising him or her of the right to make written submissions to the panel.
(6) The member shall be given at least 14 days after receipt of the mediator's report and recommendations to make written submissions to the panel or to request an appearance before the panel to make oral submissions, or to do both.
(7) A member who requests an appearance shall be given a reasonable opportunity to make an appearance, but the panel may dispose of the matter without such appearance if the member has been given a reasonable opportunity to appear.
(8) If the mediation concerns a matter referred by the Complaints Committee, the chair shall give the complainant a copy of the mediator's report.
(9) A mediator's proposed resolution of a matter referred to the Committee by the Complaints Committee must be acceptable to the complainant, the member complained against and the panel.
(10) A mediator's proposed resolution of a matter referred to the Committee by the Executive Committee must be acceptable to the member complained against and the panel.
(11) After considering the mediator's report and any written or oral submissions, the panel may require the member to undergo an assessment for the purpose of establishing if he or she requires education with respect to sexual abuse.
(12) The assessment shall be carried out by an assessor appointed by the Committee.
(13) The assessor shall provide a written report to the panel and shall make such recommendations as the assessor considers appropriate about the member's need for education with respect to sexual abuse.
(14) A copy of the report and recommendations, and a notice informing him or her of the right to make submissions in accordance with subsections (6) and (7), shall be provided to the member.
(15) After considering the assessor's report and recommendations and the member's submissions, if any, the panel may require the member to attend or participate in a sexual abuse education program.
(16) If the panel proposes to take action under subsection (15), the member has the right to make submissions in accordance with subsections (6) and (7). O. Reg. 98/98, s. 2.
50. (1) If a member refuses to undergo an assessment under subsection 49 (11) or to attend or participate in a program under subsection 49 (15), the panel may direct the Registrar to impose terms, conditions or limitations on the member's certificate of registration for a specified period not exceeding six months.
(2) If the panel proposes to take action under subsection (1), the member has the right to make submissions in accordance with subsections 49 (6) and (7).
(3) If the panel is satisfied that the terms, conditions and limitations imposed on a member's certificate or registration are no longer needed, it shall direct the Registrar to remove them before the end of the specified period.
(4) If, at the end of the specified period, the member continues to refuse to undergo the required assessment or to attend or participate in the program, the panel shall refer the matter to the Executive Committee. O. Reg. 98/98, s. 2.
Panel Requirements
51. (1) The Committee may sit as a panel to consider a report on a practice review or any matter arising out of a practice review, a matter relating to the imposition of terms, conditions or limitations on a member's registration under section 48 or a matter under section 49.
(2) A panel shall have at least three members appointed by the chair of the Committee from among the Committee members; at least one member of the panel shall be a member appointed to the Committee by the Lieutenant Governor in Council.
(3) Three members of a panel constitute a quorum. O. Reg. 98/98, s. 2.
Terms, Conditions and Limitations, Part B Pharmacist
9. (1) Every certificate of registration of a pharmacist listed in Part B of the register is subject to the following terms, conditions and limitations:
- 1. The member shall not provide any care to a patient, whether direct or indirect.
2. The member shall not dispense, sell or compound drugs.
3. The member shall not supervise that part of the pharmacy where drugs are kept.
4. The member shall not be the designated manager of a pharmacy within the meaning of the Drug and Pharmacies Regulation Act.
5. The member shall not supervise the practice of pharmacy of an intern, registered pharmacy student or pharmacy technician.
6. The member shall, when working in a pharmacy or any other environment where patient care is being provided, clearly identify him or herself as a non-practising pharmacist. O. Reg. 451/10, s. 1.
(3) Where a member wishes to seek the approval of the Registrar under subsection (2), the member shall provide to the Registrar, in writing, the name of the pharmacist or pharmacists who will be providing the required supervision, the name and address of the pharmacy or pharmacies at which the member proposes to practise under that supervision and the proposed date upon which the member wishes to commence practice. O. Reg. 451/10, s. 1.
(4) Any approval provided by the Registrar under subsection (2) must specify,
- (a) the name of the pharmacist or pharmacists who will be required to supervise the member;
(b) the name and address of the pharmacy or pharmacies where the member will be practising; and
(c) the term of the approval, which must not exceed six months. O. Reg. 451/10, s. 1.
