Peer and Practice Assessment Policies

The Purpose of the Colleges’ Practice Assessment is:

  • To meet statutory obligations under the Regulated Health Professions Act (RHPA), 1991
  • To assure the public and stakeholders that Registered Dietitians (RDs) practice safely, competently and ethically.
  • To provide positive reinforcement to RDs who provide safe, ethical and competent nutrition services.
  • To assist RDs in improving their individual competence in a positive and supportive environment using processes that are flexible and acceptable to members.

Notification

The RHPA states that a member required to undergo a peer and practice assessment is entitled to at least 14 days’ notice of the start of the assessment. Members randomly selected for the Practice Assessment (PA) will be notified in March of every year of their requirement to complete a PA.

Compliance

The College’s PA is mandatory for all members whether selected randomly or otherwise. If a member does not fully participate in the PA or cooperate with an assessor or the QA Committee, the Committee may refer the matter to the Inquiries, Complaints and Reports Committee.

Expectation

Cooperation with the QA Committee and/or the College Assessor means that members are required to do any or all of the following:

  • participate in the PA program designed to evaluate the knowledge, skill and judgment of the member;
  • permit assessor/s to enter and inspect the premises where the member practices;
  • permit the assessor to inspect the member’s records of the care of patients;
  • provide the Committee or the assessor with all information related to the care of patients, in the form the Committee or assessor specifies; and
  • confer with the Committee or the assessor if requested to do so.

Format

A pre-assessment questionnaire will identify specific assessment tools for the member based on the member’s own practice. This questionnaire will complement and/or confirm information about the member on the CDO database by asking questions pertaining to the scope of practice, types of clients, type of services provided, area of practice, work setting, team members and performance appraisal systems.

The Peer and Practice assessment may also include, but is not limited to one or more of the following assessment methods, which may be conducted together, sequentially or in stages:

  • Requiring the member to answer, orally or in writing, questions that relate to the member’s practice;
  • Requiring the member to solve simulated problems or case studies that relate to the practice of dietetics;
  • Reviewing client records and the member’s self-assessment and professional development records; and
  • Interviewing or surveying the member and his or her employer, employees, colleagues, peers and, clients.

Policy Statement

Each year the College shall randomly select the names of eligible members required to undergo the College’s Peer and Practice Assessment. A member may be required to undergo the College’s Peer and Practice Assessment for other reasons as well (e.g., non- compliance with other QA requirements such as the SDL tool or JKAT or as directed by the Quality Assurance Committee (QAC).

Procedure

1. Members Eligible for Random Selection
  1. The College will randomly select 10% of its members in March of every year.
  2. The criteria for composition of the random pool shall exclude:
    1. Members not practicing in Ontario;
    2. Those whose certificates of registration are under suspension;
    3. Those with temporary memberships;
    4. Members who became General Members less those 12 months prior to the random selection date
    5. Members who completed the College’s Peer and Practice Assessment within the previous five years.
    6. Those entitled to automatic deferrals:
      • CDO Committee member or Council member
      • CDO Quality Assurance Staff
      • Practice Assessment Assessors
2. Referred Members

A member may be required to undergo the Peer and Practice Assessment:

  1. If the Committee finds that they have not complied with the submission of the Self-Directed Learning Tool and or the Jurisprudence Knowledge and Assessment Tool.  This includes all general members regardless of date of joining CDO, year of last PPA or place of residence.
  2. Whether or not any other action has been taken as a result of a report from a Peer and Practice Assessment and the Committee concludes that a re-assessment is warranted.
  3. If the member meets other criteria established by the Committee that are published and distributed to members. 
3. Automatic Deferrals

If a member, who is in one of the positions listed below, is randomly selected from a pool of members, they will be deferred from the Practice Assessment for a period of one year following the last date of their term; the last date they acted as a College Assessor; or the last date they worked at the College. Automatic deferrals are granted to these members to reduce or eliminate any advantage to the member or appearance of bias that might accrue from their involvement.

  • CDO Council members
  • CDO Quality Assurance Committee and Staff
  • Practice Assessment Assessors
 

If any of the above members are eligible due to grounds other than random selection, they will be required to complete the Practice Assessment.

In such a case, the QA Committee may consider modifying the Practice Assessment to reduce or eliminate any advantage to the member or bias that might accrue from their involvement. In addition, the Committee may consider whether steps should be taken to modify or even suspend the involvement of the member as a Committee member, Assessor or Staff as a result of the reasons for referral.

Resignation after Random Selection

A member who resigns from the College after they have been selected for the College’s Peer and Practice Assessment, but before the date of the scheduled Peer and Practice Assessment, will not be required to complete the peer and practice assessment.  If the member reapplies for membership, upon reinstatement, the member will be required to complete the Peer and Practice Assessment at the next cycle.

Policy Statement

Each year the College shall randomly select the names of eligible members required to undergo the College’s Peer and Practice Assessment. A member may be required to undergo the College’s Peer and Practice Assessment for other reasons as well (e.g., non- compliance with other QA requirements such as the SDL tool or JKAT or as directed by the Quality Assurance Committee (QAC).

Procedure

  1. 10% of eligible members are selected to participate in Step 1 of the PPA-Multisource Feedback Surveys. The 2 Step PPA process is attached as appendix A
     
  2. Each member is required within 90 days of notification to:
    • Complete a Self-Assessment survey
    • Submit at minimum 6 Colleague Surveys *
    • Submit at minimum 9 Patient Surveys (if applicable) *
  3. Once the survey results are compiled, members whose multisource feedback scores fall outside the reference criteria and a random selection (3%) of members who score at or above the reference criteria set by the QA Committee progress to Step 2- the Behaviour-based Interview and chart review/stimulated recall
     
  4. The QA Staff sends each member their Step 1 feedback results and the next steps (if any) in the 2 Step PPA. Anyone who is not required to move onto Step 2 is considered to have completed the PPA and is removed from random selection for the next 5 years.
     
  5. Members moving onto Step 2 will be notified online of each step of the process. The specific procedure is summarised in appendix B.

*If at least 6 Patient Surveys and at least 4 Colleague Surveys have been received and feedback is positive, these constitute completion of Step 1 PPA.

2 Step PPA Process Diagram Step 2 Process Diagram

Policy Statement

Members of the College may formally request that a Peer and Practice Assessment be delayed if there are extenuating circumstances. Requests that meet objective criteria set in policy are granted by staff on behalf of the Committee but no request is refused without first being considered individually by the Committee.

Procedure

1. Filing of a Request
 

A request to defer the PPA should be made by email, fax or letter (on the form provided by the College). The request may be made on behalf of the member if the member is unable to make the request themselves. The College should receive the request for deferral by the deadline indicated on the deferral form. In certain circumstances, it may be necessary to file a request after this time period. In these cases, the member must give their reason for the delayed request.

2. Details of the Request

The written request may include the following:

  1. The member’s name and registration number clearly identified;
  2. An indication of current work status;
  3. Any information/reasons that is pertinent and supportive of the request and would assist the College in making its decision; and
  4. Other information as requested e.g doctor's note.

The decision may be delayed or the request for extension or deferral denied if there is insufficient information to make the decision.  In this situation, the member will be notified, in writing, and may choose to provide further information.

3. Committee/Staff Decisions Regarding a Request for Deferral

 

3.1 The member will be notified by email, generally within five business days, of receipt of his/her request. 

3.2 Members who were randomly selected for a Practice Assessment and cannot complete it due to reasons such as:

  • Illness or disability
  • Bereavement
  • Personal hardship
  • Leaves of absences
  • Maternity or parental leave
  • Current hospitalization

will be deferred and will be required to complete the PPA the following year’s Practice Assessment period.

3.3 Referred members requesting a deferrals will be reviewed by the Committee on a case-by-case basis.

3.4 If a request for deferral of a specific time frame is made, the College may consider this time frame but will not be limited by it.

3.5 The member will be notified, in writing, of the College’s decision.  This notification will be emailed to the member generally within five business days of the College’s decision.

Policy Statement

Upon receipt of an Assessor’s report, members shall be informed of their right to make a submission to the Quality Assurance Committee before the Committee makes a decision.  The Committee shall consider the member’s submission as well as the Assessor’s report when making a decision.

Procedure

Any member of the College who wishes the Committee to consider other facts or information (a submission) before a decision respecting an Assessor’s report of a Peer and Practice Assessment should make a submission online through the College website. 

The submission should be sent within 14 days from the date of the notification of the Assessor’s report. The member will receive an automatic notification that their submission was received by the College. 

A Committee/Panel Decision Regarding a Member’s Submission

The Committee, or a panel thereof, will consider both the member’s submission and the assessor’s report to determine next steps: 

  1. Accept the assessor's report and continue with the PPA process
  2. Require member to undergo a second PPA (Step 2) with the same or different assessor
  3. Any other remedy within the authority of the Committee

The Committee may require the member to pay for the cost of a new PPA depending on the circumstances.

A decision may be delayed if the Committee requires additional information to make a decision.

Policy Statement

Members shall have the right to request that the Quality Assurance Committee reconsider their decision respecting an Assessor’s report for a Peer and Practice Assessment.  The Committee shall consider a member’s request to have a decision reconsidered.

Procedure

1. Filing of a request

1.1 Any member of the College who wishes the Committee to reconsider their decision respecting an Assessor’s report of a Peer and Practice Assessment should request one in writing.

1.2 The College should receive the request 30 days from the date of the letter of notification of the Committee’s decision.  The request may be mailed, faxed or sent to the College electronically.

1.3 The member will be sent a letter within 5 business days of receiving the request acknowledging receipt of his/her request.  The member may also be contacted by other means.

2. Details of the request

The written request should include the following:

  1. The member’s name and registration number clearly identified.
  2. Reason for making the request for reconsideration of the Committee’s decision.
  3. Any documentation that may be pertinent and supportive of the reason for the request for reconsideration of the Committee’s decision that would assist the Committee in its deliberation.
3. A Committee/Panel Decision Regarding a Request to Reconsider a decision:

3.1 The Committee, or a panel thereof, will consider the request on an individual case basis.  This will include a review of documents sent in by the member, the Committee decision and the assessor’s report/s on the Peer and Practice Assessment. 

3.2 The Committee, or a panel thereof, may choose between the options listed below:

  1. Do nothing and continue with the peer & practice assessment and enhancement process as per the QA Regulation and policies;
  2. Require the member to undergo a new peer and practice assessment with the same or a different assessor;
  3. Any other remedy within the authority of the Committee.

3.3 The Committee’s decision regarding the request for reconsideration will be communicated in writing to the member within 5 business days of the date the decision is made.

3.4 The Committee may require the member to pay for the cost of a new peer or practice assessment depending on the circumstances.

3.5 A decision may be delayed if the Committee requires additional information to make a decision.

Policy Statement

A member, who has a disability (defined below according to the Human Rights Code) and requires special accommodation for that disability in order to complete the assessment, may request that the College make those provisions. The College of Dietitians will work with the member to accommodate their needs ensuring that self-worth, individuality, privacy, confidentiality comfort and autonomy is maintained.

Procedure

  1. A request in writing or some other permanent medium should be received at least 30 business days before the date of the assessment or before the assessment date is arranged. Requests received later will be reviewed, but may result in a delaying the practice assessment in order to make any necessary accommodation.
  2. The request from the member must include documentation of the relevant nature disability and a description of the special accommodation requested.
  3. The College will work with the member to accommodate their special needs and ensure that the member has a fair opportunity to demonstrate competence.
  4. Temporary or permanent measures may be necessary to ensure that the member can participate in the Peer and Practice Assessment in a timely manner.
  5. The College will assume any costs incurred as a result of accommodating a member’s special need.

Policy Statement

The Quality Assurance Committee appoints qualified Registered Dietitians to conduct Peer and Practice Assessments in a fair, confidential, secure and standard format. Assessors conduct Peer and Practice Assessments and prepare reports for the Quality Assurance Committee in accordance with established procedures approved by the College.

Procedure

  1. The Registrar & ED and Quality Assurance Staff will recruit Assessors for the Peer and Practice Assessments based on a written job description outlining qualifications, roles and responsibilities[i]. Positions will be advertised in resume and selection will be based on submission of a resume, letter of application, an interview and references.
  2. Staff will submit names of qualified Registered Dietitians to the Quality Assurance Committee for appointment as a College Assessor.
  3. The Registrar and Executive Director and Quality Assurance Staff will set rates for compensation for Assessors based on market value.
  4. Assessors will sign a contract with the College that outlines expectations[ii] including number of assessments expected to be conducted over a specified time period, roles and responsibilities, compensation, confidentiality, conflict of interest, and term of contract.
  5. Assessors will be provided with appropriate training by the College.

The Committee will appoint an assessor for each assessment. This may be done by a single motion where the next available assessor on a roster of assessors is matched to the member to be assessed using objective criteria.


[i] See Roles and Responsibilities of College Assessors
 
[ii] See Contract for Assessors.