Notices to the Professions

Notice to the Professions /
CSHBC Quality Assurance & Professional Practice Program, Practice Review Module FAQs

We continue to receive questions regarding the College’s Quality Assurance & Professional Practice (QAPP) Program, Practice Review Module. The purpose of this Notice to the Professions is to answer common questions we have received regarding practice reviews.

Overview of Practice Reviews

1. What laws authorize the QAPP Program & Practice Reviews?

The College’s Quality Assurance & Professional Practice (QAPP) Committee (the “QAPP Committee”) administers the QAPP Program and the Practice Review module pursuant to the Health Professions Act (HPA) and the College’s Bylaws.

  • Sections 26.1 and 26.2 of the HPA allow for an assessment of professional performance. 
  • College Bylaws 24(1) and 160, establish the College’s QAPP Committee and provide mandatory elements of a professional performance assessment.

2. What is a Practice Review?

Practice Reviews are one module of the QAPP Program. A Practice Review’s goal is to ensure College registrants are meeting competency standards. The Practice Review module is intended to support registrants and their practice by proactively reviewing for compliance with standards. The module provides for a continuous cycle of quality assurance and performance measurement amongst College registrants.

3. Are registrants required to participate in Practice Reviews?

Yes. All College registrants have a duty to comply with their professional regulation requirements, including the QAPP Program and Practice Reviews. A refusal to participate may result in professional discipline.

4. What does a Practice Review look like?

Practice Reviews occur in two stages:

  • First Stage (Screening): QAPP Practice review screeners review documentation identified by the registrant that reflect clinical and ethical standards of the registrant’s practice. Documentation is redacted and screening are conducted anonymously.
  • Second Stage (Assessment): Registrants who do not successfully pass the screening stage must undergo an in-person, onsite practice review.

For an overview of this process, please see the Practice Reviews page, which includes an instructional video.

Questions About the Screening Stage

5. How does the Screening Stage work?

Registrants selected for a Practice Review will receive a letter from the College requiring that redacted documentation, including client or patient files be provided for screening.

An appointed QAPP Practice Review screener will review the requested documentation. If the screening of the files identifies no practice or ethical issues, a registrant will have completed the Practice Review process.

Where the screening identifies issues that require further review, the College will notify a registrant that an in-person, onsite assessment will be required.

6. How is documentation, including client or patient files, selected for screening?

The College’s letter notifying a registrant has been selected for a Practice Review will require registrants to identify documentation that reflect certain clinical and ethical standards of their practice.

Registrants who have direct access to their client or patient files will be responsible for redacting and providing the identified documentation. Registrants who are employed by a health authority, a school board, or other institution where they do not have direct access to disclosing files will be asked to provide a list of the files to the College. The College will obtain the redacted files from the institution.

Questions About the Assessment Stage

7. How does the Assessment Stage work?

Where the screening identifies issues that require further review, the QAPP Committee will notify a registrant that an in-person, onsite assessment will be required.

The letter of notification will advise that a College appointed QAPP Practice Review Assessor will be contacting the registrant to coordinate for the in-person, onsite assessment.

The letter of notification will advise that a College appointed QAPP Practice Review Assessor will be contacting the registrant to coordinate for the in-person, onsite assessment.

8. What Information is released to the Assessor or my employer?

No information about the outcome of the screening stage is released to the Assessor. The Assessor will conduct a general assessment. The Assessor will explain what is required and work with a registrant (and their employer or service contractor, if applicable) to coordinate the in- person, onsite assessment.

No detailed information about the outcome of the screening stage is released to a registrant’s employer or service contractor. As the Assessor may need to coordinate with a registrant’s employer or service contractor, the Assessor may need to discuss the planning of the Assessment with a registrant’s employer or service contractor.

9. Must registrants obtain client consent for an Assessor to be present?

Yes. Registrants must obtain client consent regarding the presence of an Assessor in advance of a Practice Review. The Assessor will assist a registrant (and their employer or service contractor, if applicable) in obtaining the consents required.

10. How long do Assessments take?

The Assessor will typically require one business day, possibly two, to complete a practice review. However, the Assessor has the discretion to perform a longer or shorter assessment depending on the circumstances of any particular case.

11. What happens after the Assessment?

The Assessor may advise that there are no remedial recommendations needed, which completes the Practice Review process. The Assessor may also advise there are minor or major remedial recommendations regarding a registrant’s practice.

12. What happens if there are minor recommendations?

Where the Assessor identifies minor recommendations, the Assessor will prepare a remediation plan and continue to work with the registrant. Once any minor recommendations have been successfully remediated, the Practice Review process is completed. The plan may include a follow-up assessment by the Assessor.

13. What happens if there are major recommendations?

Where the Assessor identifies major recommendations, a profession specific QAPP Committee panel will review the Assessor’s remediation plan for its approval before implementation and will also monitor for the successful completion of the plan. The plan may include a follow-up assessment by the Assessor.

Major recommendations are made by an Assessor where for example, there are serious deficiencies that are a potential danger to the public, where there is unauthorized practice, or where there is a significant pattern of substandard practice.

Questions About Confidentiality and Privacy

14. Are the reviews confidential?

Yes. Practice Reviews are confidential.

The registrant is not required to share any outcome or recommendation with their employer. The QAPP Committee will not disclose information or records it gathers through the QAPP Program to any other College committee (e.g. the Inquiry committee) or person (e.g. registrants’ employers) subject to exceptions in the HPA, other enactments, or a court order.

This confidentiality extends to the following types of records or information:

  • records and information provided by a registrant, including self-assessments;
  • records and information provided by third parties regarding a registrant;
  • conclusions and assessments of a registrant’s practice, including reasons for screening and any recommendations or remediation plans regarding a registrant’s practice.

NOTE: this confidentiality is not absolute – the QAPP Committee may disclose confidential information to other persons or committees (see Question 15 below).

15. What are the exceptions to confidentiality? When can the QAPP Committee disclose Practice Review information?

The HPA authorizes and, in some cases, requires the QAPP Committee to share information it receives with other committees or persons.

The QAPP Committee may disclose confidential information to show that a registrant has submitted false information to it or to a provincial health officer for the purpose of reporting a risk of significant harm to health or safety of the public.

The QAPP Committee must notify the Inquiry Committee if, on reasonable grounds, it believes a registrant has committed and act of professional misconduct or incompetence, is impaired by reason of a physical or mental ailment or the registrant’s failure to comply with a quality assurance recommendation poses a threat to the public. In any of these situations the QAPP Committee must also believe that notifying the Inquiry Committee is necessary to protect the public.

The QAPP Committee may also report to a provincial health officer or a medical health officer for the purpose of reporting a risk of significant harm to the health or safety of the public or a group of people.

16. What happens to records submitted to the QAPP Committee after the assessment?

The QAPP Committee will securely destroy any records it receives after the successful completion of a Practice Review. The QAPP Committee may, in certain circumstances, disclose records to another person or committee. See (see Question 15 above) for more information on this topic. The QAPP Committee will only use records it receives for purposes authorized by the HPA.

17. Is the College’s QAPP Committee subject to the Freedom of Information and Protection of Privacy Act (FIPPA)?

No. FIPPA does not apply to records and information the QAPP Committee receives as part of the QAPP Program. These records are subject to confidentiality provisions under s. 26.2(1) of the HPA. Such records are confidential, apart from the exceptions contained within that section.

NOTE: this issue is subject to developing legal precedent and may vary in the future.

Questions From Employers or Service Providers

The College recognizes that many of its registrants do not work in a private practice setting. The purpose of this section is to answer common questions employers or service contractors may have regarding registrants and the Practice Review module.

18. How will an employer or service contractor know that an Assessment is required of a registrant?

The QAPP Committee or College will send a letter advising that a registrant must undergo an in- person, onsite assessment. The letter will set out the process and provide a contact person to discuss any coordination that will be required. The letter will also provide the name and contact information for the assessor.

Coordinating issues may include timelines, institutional policy requirements, disclosure issues, and special client or patient or staff sensitivities.

19. Are employers or service contractors responsible for costs associated with a Practice Review?

No. Employers are not responsible for any financial costs regarding a Practice Review. All QAPP Assessors are retained and paid by the College.

20. Are registrants in a Practice Review module required to obtain client consent to the presence of an Assessor?

Yes. Registrants must obtain client consent that meets the College’s standards and the employer or service contractor’s policies (see Question 9). An employer or service contractor may also require that an Assessor meet its specific consent policies.

21. Will employers receive notice of why a registrant’s practice was screened for an in- person, onsite assessment?

No. These results are confidential to promote candour between a registrant and the QAPP Committee within the QAPP Program. A registrant being screened does not indicate any practice or ethical issue with the registrant’s practice.

22. Will employers receive any recommendations made by Practice Review Assessor?

No. These results are confidential to promote candour between a registrant and the QAPP Committee within the QAPP program.

23. Will the College or QAPP Committee ever share the information from a Practice Review?

In some situations. The QAPP Committee may report to a provincial health officer or a medical health officer for the purpose of reporting a risk of significant harm to the health or safety of the public or a group of people.

The QAPP Committee must also notify the Inquiry Committee if it has reasonable grounds to believe that the registrant’s conduct amounts to professional misconduct, demonstrates professional incompetence, or that the registrant has an impairing condition under s. 33(4)(e) of the HPA.

For further information, please contact Mardi Lowe, Director, Quality Assurance & Professional Practice at Mardi.Lowe@cshbc.ca.

College of Speech and Hearing Health Professionals of British Columbia

Address:
630 – 999 West Broadway
Vancouver BC V5Z 1K5

Phone: 604.568.1568
Email: enquiries@cshbc.ca