Independent Health Facilities

Licensed IHFs

The Ministry of Health and Long-Term Care (MOHLTC) license IHFs that provide OHIP-insured services, such as:

• In diagnostic facilities: radiology; ultrasound; magnetic resonance imaging; computed tomography; nuclear medicine; positron emission tomography (PET); pulmonary function studies; and sleep medicine.
• In ambulatory care facilities: surgical, therapeutic and diagnostic procedures which include dialysis, abortion, laser dermatologic surgery and ophthalmic, vascular, plastic, endoscopy and gynaecologic surgery.

How is a facility chosen for assessment?

The MOHLTC annually selects IHFs for the CPSO to assess. We must assess every IHF in Ontario at least once during its three-to-five-year licensing period. The director of the MOHLTC’s Independent Health Facilities program may also request the CPSO perform an assessment “where the director considers it necessary or advisable.”

The assessment of each facility is based on adherence to Clinical Practice Parameters and Facility Standards, developed for services offered in IHFs. In the absence of specific guidelines, we assess the IHF’s adherence to the current generally accepted medical standard of practice.

Who conducts the assessment?

The CPSO selects an assessment team composed of a specialty-specific peer physician and a technologist or nurse depending on whether the assessment is of a diagnostic or ambulatory/surgical facility. We notify the IHF selected for an assessment and request they arrange a mutually convenient time to meet the assessment team.

The assessment team meets with the facility’s owner/operator, quality advisor and other relevant staff members. The following information should also be available for review:

• Quality advisor’s agreement with the facility;
• Policies and procedures manual;
• Preventive maintenance, equipment and supply records;
• Staff qualifications and CPD compliance;
• Performance of the facility’s licensed patient procedures;
• Patient requisitions, films/charts and reports;
• Requesting and reporting mechanisms for diagnostic procedures; and
• Quality management activities.

Note:

1. The assessors may request copies of some documentation to take with them.
2. The MOHLTC may ask the CPSO to conduct quality assessments and inspections on IHFs without advance notice where there is a follow-up assessment/inspection or an assessment arising from a complaint.

What happens after they complete the on-site assessment?

The assessment team submits a report outlining its findings to the CPSO, identifying if the facility meets or is in breach of practice standards. If the facility is in breach, the report also indicates how the facility can improve to meet the standards of their specialty. The IHF receives a copy of the assessment report and must return a written plan of action within 14 days that addresses any breaches.

We send all assessment reports to a specialty-specific facility review panel, which provides advice to the MOHLTC on whether the facility is now in compliance with relevant standards based on their response. The panel can also recommend any follow-up assessments to the MOHLTC, if warranted.

The College sends the assessment report and panel findings to the MOHLTC, who then sends those documents and their licensing decision to the facility.

If you have any questions or need assistance, please email IHF.

General Assessment Tools

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