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Follow-up Action Per Category

  1. Full accreditation; no review for five years.
  2. Necessitates planned follow-up.
  3. Referral to College of Physicians & Surgeons.
  4. No reassessment scheduled.
  5. Retired/Deceased - no reassessment

(Categories 4 & 5 assigned for database entry purposes)

NOTE: Illegibility precludes assessment (reaching a conclusion about care). A scheduled revisit or review will be carried out (which might include chart-stimulated recall) after which a final assessment category will be determined.

Assessment Statistics (1996 - 2006)

1996 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 7 1 0 1 9
B (50-64) 4 1 0 1 6
C (>64) 1 0 0 0 1
 
Gender: Male 11 2 0 2 15
Female 1 0 0 0 1
 
Urban: Regina & S'toon 10 0 0 0 10
Rural: All Others 2 2 0 2 6
 
Family Practice: 12 2 0 2 16
Specialty: 0 0 0 0 0
 
Total Annual Assessments: 12 2 0 2 16
Total Assessments to Date: 12 2 0 2 16

 

1997 Category 1 Category 2 Category 3 Revisits Total
Age Group: A (<50) 7 0 0 0 7
B (50-64) 18 0 0 1 19
C (>64) 5 3 0 1 9
 
Gender: Male 24 3 0 2 29
Female 6 0 0 0 6
 
Urban: Regina & S'toon 16 2 0 1 19
Rural: All Others 14 1 0 1 16
 
Family Practice: 30 3 0 2 35
Specialty: 0 0 0 0 0
 
Total Annual Assessments: 30 3 0 2 35
Total Assessments to Date: 42 5 0 4 51

 

1998 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 30 1 0 0 31
B (50-64) 25 7 0 2 34
C (>64) 16 3 0 2 21
 
Gender: Male 52 9 0 3 64
Female 20 2 0 1 23
 
Urban: Regina & S'toon 39 4 0 0 43
Rural: All Others 32 7 0 4 43
 
Family Practice: 71 11 0 4 86
Specialty: 0 0 0 0 0
 
Total Annual Assessments: 71 11 0 4 86
Total Assessments to Date: 113 16 0 8 137

 

1999 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 57 9 0 1 67
B (50-64) 32 2 0 1 35
C (>64) 12 0 0 2 14
 
Gender: Male 78 10 0 3 91
Female 23 1 0 1 25
 
Urban: Regina & S'toon 40 3 0 3 46
Rural: All Others 61 8 0 1 70
 
Family Practice: 101 11 0 4 116
Specialty: 0 0 0 0 0
 
Total Annual Assessments: 101 11 0 4 116
Total Assessments to Date: 214 27 0 12 253

 

2000 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 51 12 0 2 65
B (50-64) 30 8 0 2 40
C (>64) 4 4 0 0 8
 
Gender: Male 58 21 0 4 83
Female 27 3 0 0 30
 
Urban: Regina & S'toon 47 17 0 1 65
Rural: All Others 38 7 0 3 48
 
Family Practice: 78 24 0 4 106
Specialty: 7 0 0 0 7
 
Total Annual Assessments: 85 24 0 4 113
Total Assessments to Date: 299 51 0 16 366

 

2001 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 40 2 0 1 43
B (50-64) 35 8 0 2 45
C (>64) 4 1 0 3 8
 
Gender: Male 60 11 0 5 76
Female 19 0 0 1 20
 
Urban: Regina & S'toon 37 5 0 4 46
Rural: All Others 42 8 0 2 52
 
Family Practice: 73 11 0 6 90
Specialty: 6 0 0 0 6
 
Total Annual Assessments: 79 11 0 6 96
Total Assessments to Date: 378 62 0 22 462

 

2002 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 53 2 0 2 57
B (50-64) 26 2 1 6 35
C (>64) 3 1 0 1 5
 
Gender: Male 60 3 1 8 72
Female 22 2 0 1 25
 
Urban: Regina & S'toon 38 2 1 7 48
Rural: All Others 44 3 0 2 49
 
Family Practice: 74 5 1 9 89
Specialty: 8 0 0 0 8
 
Total Annual Assessments: 82 5 1 9 97
Total Assessments to Date: 460 67 1 31 559

 

2003 Category 1 Category 2 Category 3 Revisits Total
 
Age Group: A (<50) 41 13 0 0 54
B (50-64) 10 6 0 5 21
C (>64) 2 2 0 2 6
 
Gender: Male 39 17 0 7 63
Female 14 4 0 0 18
 
Urban: Regina & S'toon 22 8 0 1 31
Rural: All Others 31 13 0 6 50
 
Family Practice: 48 21 0 7 76
Specialty: 5 0 0 0 5
 
Total Annual Assessments: 53 21 0 7 81
Total Assessments to Date: 513 88 1 38 640

 

2004 Category 1 Category 2 Category 3 No Category (Illegible) Total
 
Age Group: A (<50) 37 9 0 2 48
B (50-64) 13 4 1 0 18
C (>64) 4 4 0 0 8
 
Gender: Male 37 14 1 2 54
Female 17 3 0 0 20
 
Urban: Regina & S'toon 24 6 1 2 33
Rural: All Others 30 11 0 0 41
 
Family Practice: 34 13 1 2 50
Family Practice Revisit: 7 4 0 0 11
Specialty: 13 0 0 0 13
Specialty Revisit: 0 0 0 0 0
 
Total Annual Assessments: 54 17 1 2 74
Total Assessments to Date: 567 105 2 2 714

 

2005 Category 1 Category 2 Category 3 No Category (Illegible) Total
 
Age Group: A (<50) 25 7 0 0 32
B (50-64) 12 4 0 0 16
C (>64) 3 4 0 0 7
 
Gender: Male 30 11 0 0 41
Female 10 4 0 0 14
 
Urban: Regina & S'toon 23 4 0 0 27
Rural: All Others 17 11 0 0 28
 
Family Practice: 23 9 0 0 32
Family Practice Revisit: 3 5 0 0 8
Specialty: 14 1 0 0 15
Specialty Revisit: 0 0 0 0 0
 
Total Annual Assessments: 40 15 0 0 55
Total Assessments to Date: 607 120 2 2 731

 

2006 Category 1 Category 2 Category 3 No Category (Illegible) Total
 
Age Group: A (<50) 26 7 0 0 33
B (50-64) 11 4 0 1 16
C (>64) 4 3 0 0 7
 
Gender: Male 27 11 0 1 39
Female 14 3 0 0 17
 
Urban: Regina & S'toon 17 1 0 1 19
Rural: All Others 24 13 0 0 37
 
Family Practice: 27 9 0 1 37
Family Practice Revisit: 3 0 0 0 3
Specialty: 11 3 0 0 14
Specialty Revisit: 0 2 0 0 2
 
Total Annual Assessments: 41 14 0 1 56
Total Assessments to Date: 648 134 2 3 787

Purpose

The Practice Enhancement Program is an educational program designed to offer the physicians of Saskatchewan a report of the health of their practices through a practice-based assessment process and to encourage continual improvement of physicians' clinical skills and office practices in order to provide high quality patient care to Saskatchewan residents.

Funding

The Practice Enhancement Program is supported through equal funding annually from the College of Physicians and Surgeons of Saskatchewan, Saskatchewan Health of the provincial government and the Saskatchewan Medical Association and is accountable to each organization for providing annual aggregate statistical information on assessments completed and financial program expenditure.

Organization

The Practice Enhancement Program is administered by a committee of six Saskatchewan physicians appointed by the College of Physicians and Surgeons of Saskatchewan, three of whom are nominated by the Saskatchewan Medical Association. The committee is Co-chaired by a nominee from the College of Physicians and Surgeons of Saskatchewan and a nominee from Saskatchewan Medical Association.

The PEP committee functions independently of the organizations represented. Information obtained in the process of an office assessment remains the property of the Practice Enhancement Program and cannot to be used by any committee of the funding organizations for any disciplinary purpose.

The program is based on the assumption that an experienced physician can review another physician's office facilities, procedures and medical records and, in combination with feedback from patients of that physician, come to a valid determination of the quality of care being provided by that physician. The committee meets regularly to review information gathered by the assessors and to make the final decision on the quality of care provided by each physician. This will enable unbiased and objective categorization of quality of care.

The tracking of aggregate information will be maintained by the Practice Enhancement Program Office. Information will be reported to the three supporting organizations as follows:

  • minutes of committee business meetings
  • annual statistics of program activity
  • semi-annual and year end fiscal reporting

Assessors

Assessments will be carried out by trained Saskatchewan Physician Assessors selected by the Practice Enhancement Program Committee based on the following criteria:

The physician assessor:

  1. Has had an office assessment carried out on his/her practice.
  2. Will have practiced in Saskatchewan for five or more years, and must be currently in practice.
  3. Must be willing to commit to carrying out four to ten assessments per year.
  4. Will not have been a subject of a review with adverse conclusion within the last five years from the College of Physicians and Surgeons of Saskatchewan, the Joint Medical Professional Review Committee, or any significant body determining adequate competency.
  5. Is not a current member of the College Council, SMA Board or the Joint Medical Professional Review Committee (JMPRC).

Selection of Physicians Eligible for Assessment

  1. All Saskatchewan practicing physicians are eligible to participate at least once every five years.
  2. Possible exemptions:
    a) physicians completing a residency within the previous five years.

    b) family physicians who participated in the College of Family Physicians of Canada PASS Program within the previous five years.

    c) physicians in exclusively administrative roles or hospital-based practice such as administrative medicine, emergency and laboratory medicine.

    d) physicians who have been assessed within the past five years.

    e) physicians who have not practiced in Saskatchewan for at least three years.
  3. Selection is based on a stratified randomized selection (within identified groupings of doctors, individuals will be randomly selected.)

    Groupings:

    • greater than 65 years of age
    • 50 - 64 years of age
    • less than 50 years of age
    • family physicians
    • specialists
  4. Under no circumstances will assessments be conducted on physician practices referred to the Practice Enhancement Program or requested by a physician to fulfill a requirement of another agency.

Categories

The Practice Enhancement Program Committee will categorize the physician on the following basis:

Category 1 Consistent good care, no concerns re; patient care or records
Category 2 Acceptable, but significant need for improvement in areas listed
Category 3 Immediate Cause for Concern - Serious risk of harm to a patient

Follow-up action per category:
Category 1 full accreditation, no review for five years
Category 2 necessitates planned follow-up
Category 3 referred to the College


Legibility: Illegibility precludes assessment (reaching a conclusion about care). A review will be carried out after a specified period of time, which might include chart-stimulated recall.

PEPSask mandateOver the course of a number of assessments carried out in walk-in medical clinics the Practice Enhancement Program (PEP) has identified a number of issues that have, up till now, reduced the effectiveness of the Program. The most important component of PEP has been, and remains, its ability to offer "enhancement" to the practices which it assesses. Management arrangements in some, though by no means all, walk-in clinics have thwarted this enhancement process.

Read more: PEP's Mandate Expanded

  1. Physician Selection

    - annual selection is based on a stratified random selection (within identified groupings of doctors, individuals will be randomly selected.)
    Groupings:
    greater than 64 years of age
    50 - 64 years of age
    less than 50 years of age
    ]
    ] - family physicians
    ]
    Specialists will be assessed by entire section specialty (dermatology, pediatrics, etc.) as determined by the PEP Committee.
  2. Pre-visit Questionnaire

    - establishes a demographic and professional profile of the physician being assessed. This information will also determine eligibility for assessment.
  3. Patient Questionnaire

    (family physicians & specialists) - sent by PEP to 60 patients selected by the physician to survey patient impressions in areas such as communication, availability, staff performance and preventative medicine. A summary report is created from all patient responses and presented to the assessed physician.
  4. Referred Specialist Questionnaire

    (family physicians) - to survey the quality of referrals sent by family physicians to specialists. A list of specialist physicians, that the family physician being assessed has referred patients to recently, will be provided to PEP from the Medical Services Branch of Saskatchewan Health (no financial information is received or reviewed by PEP). Twenty specialist names will then be randomly chosen for distribution of this questionnaire.
  5. Referring Physician Questionnaire

    (specialists only) - sent by PEP to 20 referring physicians selected by the specialist to survey how colleagues perceive the specialist's services in areas such as communication, availability, and patient satisfaction. A summary report is created from all patient responses and presented to the assessed physician.
  6. Physical Facilities & Practice Organization Questionnaire

    - the purpose of this questionnaire is to collect standardized information prior to each assessment regarding facility and practice organization.
  7. Full Office Assessment

    Office visit - a physician assessor visits the office and assesses the physical facility, staff and equipment. The assessor reviews at least 20 patient charts, using a predetermined format to assess chart content and quality of care.
    Physician interview - immediately after the office visit, the assessor meets with the physician being assessed and reviews the results of the assessment. The assessor also presents the results of an annual profile, received from Saskatchewan Health (Medical Services Plan), so that the assessed physician can see a description of the demographics of his/her practice as well as to see how his/her practice profile compares to their peer group. This annual MSP profile is provided on an informational basis alone. PEP does not receive or review any financial information from Saskatchewan Health. During the interview, the assessor may point out areas of strength in the practice and also areas for possible improvement.
  8. Final Report

    - the assessor's report is submitted to the PEP committee which determines the final category for the assessed physician. The Final Report is then sent to the assessed physician. In most cases, recommendations for improvement are made but no follow-up review is needed. In some cases, PEP makes recommendations for improvement and arranges to review the practice again. This may take the form of a follow-up letter to ensure that deficiencies have been corrected or may require another office visit. A very small number of practices (in other jurisdictions, 1% or less) may be found very deficient or dangerous to patients. In these cases, PEP does not pursue the assessment further and is required to report the matter to The College of Physicians and Surgeons of Saskatchewan.
  9. Post-assessment questionnaire

    - sent to the assessed physician with the Final Report as an invitation to provide feedback to PEP on the assessment process and its value.
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