www.pepsask.ca

Home

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 quality 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 
  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.

Streaming Process:

The Practice Enhancement Program will stream physicians using information from the following:

  • MCC360 Multisource Feedback Survey
  • MCC360 Telephone Interview – provided by a trained peer assessor
  • Risk criteria developed by the PEP committee.

The risk criteria are derived from robust experiences elsewhere and include: age of the practitioner; whether practice is solo or with a group; whether the practice is rural or urban; whether the practice includes work in a hospital; whether there is a faculty appointment; and, whether the practitioner has learners for teaching purposes attending his/her practice.

Neither the MCC360 Multisource Feedback Survey, telephone interview, nor the risk criteria can be definitive in establishing whether the practice is of high quality or problematic, but may be suggestive and will be considered by the Practice Enhancement Program Committee in its judgement when streaming physicians.

In order to adhere to PEP’s mandate, some physicians will be randomly placed in Stream 2, regardless of their results on the MCC360 survey or any risk criteria.


Assessment Streams:

Stream 1:      Assessment is complete. No further action required.
Stream 2:      A Complete In-office Assessment is required and additional information will be requested. This stream will include a chart review, facility review, as well as a face to face interview with one of PEP’s trained assessors.


Stream 2 – Complete In-office Assessment

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 at least 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 mandate

Continuity of Care of your Existing Patients

Providing continuity of care for our patients including after hours and on weekends is one of the responsibilities that goes with the privilege of practising medicine. It is a requirement of the Code of Ethics1 and to be in compliance with the policy of the college of Physicians and Surgeons of Saskatchewan.2 Of course, no one can, or should try to be, available 24 hours a day, every day all year; that is why we should practise in groups with peers.

Unfortunately it has been an observation of the Practice Enhancement Program that some doctors do not have such arrangements whilst others do, but there is no way that patients can know that high standard of care being provided.

For those who do not have such arrangements you must make them. It can include participating in a group or a mutually agreed and documented reliance on coverage of the emergency department, principally the case in smaller communities. Having made such arrangements it is then necessary to be sure that patients calling for assistance after hours are informed by the answering machine.

For those physicians who appropriate arrangements, which is many of us, too often the answering machine message for after-hours simply says, if it is an emergency call 911 and then may only provide clinic hours. The patient is left adrift and uninformed. It does not tell a patient calling the office how to reach that doctor, or designate, with a concern that is not an emergency department over burdens already heavily burdened resources. For many patients the opportunity to speak with the doctor or someone covering for that doctor can provide an assessment of the problem and then informed and educated advice as to actions to take and/or the need for an office appointment very soon.

Consider setting up your answering machine as follows:

This is the office of Dr.__________. The office is now closed.

If this is an emergency call 911.

If your concern can wait, please call back during regular clinic hours, which is e.g. Monday-Friday from 9:00 - 4:30.

If your concern cannot wait, and you need advice or to talk to a doctor before the next regular clinic day, then call  {insert phone number}   to reach the physician on call.

 

1. CMA Code of Ethics and Professionalism, 2017 Canadian Medical Association

2. College of Physicians and Surgeons Of Saskatchewan. Policy: Medical Practice Coverage

 

Walk-in Medical Clinics

Over 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 of Family  Physicians is based on random stratified selection.
    - 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. MCC360 Multisource Feedback Survey

    - All physicians will be enrolled into this survey by the Practice Enhancement Program.
    - This survey is a tool used to assess physicians in their CanMEDS or CanMEDS-Family Medicine roles of a Communicator, Collaborator, and a Professional.
    - The survey will provide feedback from patients, physician colleagues, and non-physician co-workers.
    - The MCC360 report focuses on providing physicians with meaningful and actionable feedback to guide professional development and improve patient care. The report is accompanied by a feedback and coaching session with a trained facilitator to allow the physician to view the results in an objective and constructive manner, and to help develop an action plan for positive change.
  4. Streaming Process

    - Streaming is based on the MCC Multisource Feedback Survey, the Telephone Interview, and Risk Criteria developed by the Practice Enhancement Program Committee.

    - Stream 1 - Assessment complete. No further action necessary.
    - Stream 2 - Complete In-Offce Assessment is required.

    Note: In order to adhere to PEP's mandate, some physicians will be randomly placed in Stream 2, regardless of their results of the MCC360 survey or any risk criteria.


           
  5. Stream 2 Assessment - Complete In-Office Assessments:

    Physical Facilities & Practice Organization Questionnaire

    - The purpose of this questionnaire is to collect standardized information prior to an office visit.

    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 and the results of assessment, PEP does not 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.
  6. 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.
  7. Post-assessment questionnaire

    - This questionnaire invites the assessed physician to provide feedback to PEP on the assessment process and its value.
You are here: Home General Category