ontario regulation 311/10
made under the
Nursing Act, 1991
Made: April 30, 2010
Approved: August 10, 2010
Filed: August 11, 2010
Published on e-Laws: August 13, 2010
Printed in The Ontario Gazette: August 28, 2010
Amending O. Reg. 275/94
1. Part IV of Ontario Regulation 275/94 is revoked and the following substituted:
21. (1) In this Part,
“assessor” means an assessor appointed under section 81 of the Health Professions Procedural Code;
“Committee” means the Quality Assurance Committee of the College.
(2) Unless otherwise specified, this Part only applies to members holding a general, transitional or extended class certificate of registration.
22. (1) The Committee shall administer the quality assurance program of the College.
(2) Any of the powers of the Committee under this Part may be exercised by a panel of the Committee appointed under this section.
(3) The chair of the Committee may select a panel of at least three members from the members of the Committee.
(4) A panel shall include,
(a) at least one member who is both a member of the Council and a member of the College; and
(b) at least one person who is a member of the Council appointed to the Council by the Lieutenant Governor in Council.
(5) Three members of a panel shall constitute a quorum.
23. The quality assurance program shall include the following components:
1. Member assessment.
2. Practice assessment.
24. (1) The purpose of the member assessment shall be to assist each member to promote continuing competence and continuing quality improvement of the member’s practice by assisting the member in,
(a) identifying the extent to which his or her practice meets current standards of practice of the profession;
(b) identifying changes in entry to practice competencies, practice environments and technology and the relevance of those changes to the member’s practice; and
(c) identifying actions which the member should take to maintain continuing competence and to continue quality improvement of the member’s practice.
(2) Each member to whom this Part applies shall participate in a member assessment in accordance with a program approved by Council.
(3) A member assessment shall include,
(a) a self assessment;
(b) a written learning plan; and
(c) if requested by the Committee or an assessor, the completion of,
(i) one or more written questionnaires, and
(ii) any other materials that, in the opinion of the Committee or an assessor, are relevant to the assessment.
(4) In order to promote continuing competence and continuing quality improvement of the member’s practice, each member shall prepare and update his or her learning plan at least once every 12 months and shall include in the learning plan a record of,
(a) the specific programs or activities that the member plans to undertake; and
(b) the specific programs or activities in which the member has participated.
25. (1) The member shall retain the learning plan as well as any written materials required to be completed as part of the member assessment for at least two years.
(2) The member shall, upon written request of the Committee, submit the learning plan and any written materials required to be completed as part of the member assessment within 30 days of receipt of that request.
(3) Each member shall at the time of payment of his or her annual fee, if requested, confirm whether or not he or she has completed the member assessment and prepared a learning plan in accordance with this Part in the previous 12 months.
26. (1) The Committee may require a member who fails to comply with subsection 24 (2), (3) or (4) or section 25, to undergo a practice assessment within the time specified by the Committee.
(2) The Committee shall give notice to the member described in subsection (1) that he or she may be required to participate in a practice assessment.
(3) If the Committee determines that the member should undergo a practice assessment, it will give notice of its determination to the member and the member shall be allowed at least 14 days to make submissions to the Committee.
(4) The Committee shall consider all information that is relevant, including the member’s submissions, and determine whether or not the member shall be required to undergo a practice assessment.
Practice Assessment and Remediation
27. The purpose of the practice assessment is to assess the knowledge, skill and judgment of the member and shall include peer assessment.
28. (1) The practice assessment shall include one or more of the following activities:
1. Requiring the member to complete one or more questionnaires.
2. Assessing the records required to be maintained by the member relating to the member assessment.
3. Requiring the member to answer questions relating to the standards of practice of the profession.
4. Requiring the member to demonstrate the application of standards of practice in clinical simulations.
5. Inspecting the member’s records, including without limitation, records relating to the care of patients.
6. Inspecting the member’s clinical practice in accordance with section 82 of the Health Professions Procedural Code.
7. Inspecting the premises where the member practises.
8. Requiring the member to participate in any other reasonable activity approved by the Committee to assess whether the member has satisfactory knowledge, skill and judgment.
(2) The Committee may require a member to undertake the same or different practice assessment activities as another member holding the same class of certificate of registration.
(3) The Committee may require a member to undertake one or more additional practice assessment activities if, in the opinion of the Committee, additional information is required to determine whether the member’s knowledge, skill and judgment are satisfactory.
29. (1) A member shall undergo a practice assessment,
(a) if required to do so by the Committee under section 26; or
(b) if the member’s name is selected in accordance with a process approved by Council.
(2) The Council may approve different processes for selection under clause (1) (b) for members holding different classes of certificate of registration.
30. (1) A member who is required to undergo a practice assessment shall co-operate fully with the Committee and any assessor.
(2) Subject to subsection (3), after a member who is required to undergo a practice assessment has completed it, an assessor shall submit a written report to the Committee respecting the assessment which shall state whether, in the assessor’s opinion, the member’s knowledge, skill and judgment are satisfactory.
(3) If, after a practice assessment the assessor believes that he or she has insufficient information to form an opinion about whether the member’s knowledge, skill and judgment are satisfactory, the assessor shall submit a written report to the Committee with recommendations about how to obtain sufficient information to enable the assessor to form his or her opinion.
(4) If, after a practice assessment has been completed, it is the opinion of the assessor that the member’s knowledge, skill and judgment are unsatisfactory, the assessor shall submit a written report to the Committee which shall include the basis for that opinion and recommendations about appropriate specified continuing education programs or remedial measures that may assist in enhancing the member’s knowledge, skill and judgment.
(5) The Committee shall provide to the member,
(a) a copy of any report made under subsection (2), (3) or (4) along with any other material received by the Committee that is relevant to the member’s assessment; and
(b) where the report was made under subsection (3) or (4), notice of the member’s right to give the Committee a written submission with respect to the assessor’s report within at least 14 days of receipt of a copy of the assessor’s report.
(6) After receiving an assessor’s report under subsection (3), the Committee shall decide what steps are needed to obtain sufficient information to complete the member’s practice assessment, including one or more of the following:
1. Appointing a new assessor.
2. Requiring the member to engage in the same or different practice assessment activities to complete the practice assessment.
3. Such steps that, in the Committee’s opinion, are appropriate to complete the member’s practice assessment.
(7) After considering all reports made by an assessor relating to the practice assessment and any other materials received by the Committee relevant to the assessment, including any written submissions made by the member, the Committee shall decide whether the member’s knowledge, skill and judgment are satisfactory.
(8) Where the Committee requires a member to participate in specified continuing education or remediation programs under section 80.2 of the Health Professions Procedural Code, it shall also specify the time period within which the requirement must be met.
(9) Where the Committee requires a member to participate in specified continuing education or remediation programs under section 80.2 of the Health Professions Procedural Code, it may also require the member to do one or both of the following:
1. Provide evidence satisfactory to the Committee that the member has complied with the requirement.
2. Undergo a practice reassessment.
(10) The Committee may appoint an assessor to assess or reassess a member, even if the assessor has conducted a previous assessment or reassessment respecting that member.
(11) An assessor who conducts a practice reassessment may review any and all assessment reports previously made respecting the member as well as any other material that is relevant to the assessment or reassessment of the member.
31. The provisions of sections 28 and 30 apply with necessary modifications to a practice reassessment provided that the Committee shall not require the member to undergo more than two practice reassessments without the member’s written consent.
2. This Regulation comes into force on the day it is filed.
Council of the College of Nurses of Ontario:
Anne L. Coghlan
Executive Director and Chief Executive Officer
Date made: April 30, 2010.