The Practice
Enhancement Program was established in 1994 as an educational program
which would offer the physicians of Saskatchewan a positive means of
assessing their medical practice. The PEP committee studied existing
assessment and remediation programs in other provinces as well as
statistical reports determining that physicians do improve when they are
given specific information identifying deficiencies and advice on how
to correct them. The program is funded jointly by Saskatchewan Health,
the Saskatchewan Medical Association and the College of Physicians and
Surgeons of Saskatchewan.
The assessment process is one of medical peer review which looks at a
physician's office facilities, procedures and medical records to
determine the quality of care being provided by that physician. The PEP
experience also allows the physician to receive feedback from patients
and peers. As assessments are completed and specific needs for
enhancement are observed, the Practice Enhancement Program recommends
educational and remedial resources to improve skills in specific areas.
In all walks of life there is need for review and assessment of
performance in order to offer the best quality of service or care. We
hope that physicians will welcome the program as an opportunity to
enhance their practice by providing incentive to improve medical
facilities and develop skills through various resources and educational
opportunities. The mandate of the Practice Enhancement Program has
recently been expanded to cover specific issues regarding the assessment
of physicians in walk-in clinics.
For further information visit the Practise Enhancement Program's website at: www.pepsask.ca
BYLAW 18(10) PRACTICE ENHANCEMENT COMMITTEE
1. There shall be a standing committee appointed pursuant to Section
6(2)(p) and 6(2)(q) of the Act for the purpose of peer assessment of
medical office practices which shall be known as the Practice Enhancement Committee.
2. The purpose of the Practice Enhancement Committee is to establish,
develop and administer an ongoing program of peer assessment of the
office practice of members of the College in the member's chosen field
to the end that the public may be served by helping members of the
College to maintain proper standards of practice in the care of patients
and the keeping of records.
3. The Practice Enhancement Committee shall be composed of six persons
appointed by the Council, three of whom shall be nominated by the
Saskatchewan Medical Association.
4. The members of the Practice Enhancement Committee shall be
appointed by the Council annually. The Council may fill a vacancy in the
Committee by appointing such person or persons as the Council thinks
appropriate.
5. Subject always to the direction of the Council, the Practice
Enhancement Committee shall conduct its business in such manner and may
adopt, use and vary such programs and forms as it sees fit.
6. The Practice Enhancement Committee may from time to time appoint
any one or more of its members or other persons as assessors and
delegate to persons so appointed the authority to conduct an assessment
and to report thereon to the Practice Enhancement Committee.
7. Every member of the College whose standards of practice are the
subject of an assessment as part of a peer assessment program shall
co-operate fully with the Practice Enhancement Committee and with its
assessors. The co-operation required of a member includes:
a. permitting assessors appointed by the Practice Enhancement
Committee to enter and inspect the premises where the member engages in
the practice of medicine;
b. permitting assessors appointed by the Practice Enhancement Committee to inspect the member's records of the care of patients;
c. providing to the Practice Enhancement Committee or its assessors
information requested by the Practice Enhancement Committee or the
assessors in respect of the care of patients by the member or the
member's records of the care of patients;
d. providing the information mentioned in paragraph 18(10)(g)(iii)
in the form requested by the Practice Enhancement Committee or its
assessors; and
e. conferring with the Practice Enhancement Committee or its
assessors when requested to do so by the Practice Enhancement Committee
or its assessors.
8. Where the Practice Enhancement Committee forms the opinion that the
information it has gathered respecting a physician indicates that:
a. the public is at an immediate risk of harm; or
b. the physician has failed, after due notice, to comply with
provisions of these bylaws pertaining to the Practice Enhancement
Program, or has otherwise failed or refused to co-operate with the
Practice Enhancement Committee in its assessment; or
c. the physician has refused to undertake remedial measures
recommended by the Committee and the Committee considers that such
refusal is unreasonable; or
d. the physician has done or failed to do something that is a serious breach of ethics; it shall report the matter to the Council in accordance with paragraph 18(10)(i) and 18(10)(j).
9. Where the Practice Enhancement Committee concludes that one or more
of the conditions in paragraph 18(10)(h) have been satisfied, the
Practice Enhancement Committee shall report the matter to the College.
When reporting such matter to the College, the Practice Enhancement
Committee shall, at first instance, provide only sufficient information
to permit the College to fulfill its responsibilities pursuant to The
Medical Profession Act, 1981. Such information shall, at first instance,
be limited to:
a. where the Committee has formed the opinion that the public is at
immediate risk of harm, the name of the physician, the conclusion of the
Committee and general information pertaining to the harm perceived by
the Committee;
b. where the Committee has formed the opinion that the physician has
failed, after due notice, to comply with the provisions of these bylaws
pertaining to the Practice Enhancement Program, or has otherwise failed
or refused to cooperate with the Practice Enhancement Committee in its
assessment, the name of the physician and sufficient particulars of the
physician's failure or refusal to permit the College to appoint a
Preliminary Inquiry Committee to investigate such failure or refusal, or
to permit the Council to lay a charge of unbecoming, improper,
unprofessional or discreditable conduct against the physician;
c. where the Committee has formed the opinion that the physician has
refused to undertake remedial measure recommended by the Committee and
the Committee considers that such refusal in unreasonable, the name of
the physician, information respecting the remedial measures recommended
by the Committee and information pertaining to the physician's refusal;
d. where the Committee has formed the opinion that the physician has
done or failed to do something which a serious breach of ethics, the
name of the physician and sufficient particulars of the physician's
action or failure to permit the College to appoint a Preliminary Inquiry
Committee to investigate such action or failure, or to permit the
College to lay a charge of unbecoming, improper, unprofessional or
discreditable conduct against the physician;
10. Notwithstanding paragraph (10)(i), if the physician with respect to
whom the report is made applies to a court to prevent action being
taken by the College, or if the physician seeks to quash an action taken
by the College, or to appeal from a decision made by the College, or if
the physician should oppose the appointment of a Preliminary Inquiry
Committee or a Competency Committee by the College, the Practice
Enhancement Committee shall provide to the College such additional
information as may be necessary to provide the Court or the College with
full information pertaining to the factual basis for the Committee's
opinion.
11. Notwithstanding paragraphs (10)(i) and (10)(j) above, the Committee
may, in its absolute discretion, provide additional information to the
College relating to the matters in paragraph 10(h) above, if the
Committee concludes that the information is required by the College to
protect the public interest.
12. The Practice Enhancement Committee shall keep confidential all
information gathered in the course of an assessment of an individual,
and shall disclose such information only in accordance with the
provisions of paragraphs (10)(h), 10(i), 10(j) and 10(k). The Practice
Enhancement Committee may provide information to the Council of a
general nature, which does not identify the physicians involved, to
permit the Council to assess the Practice Enhancement Program and to
prepare reports of a general nature to the members of the College. The
Council shall maintain confidential all information which it obtains
from the Practice Enhancement Committee and shall not utilize such
information unless:
a. If the Practice Enhancement Committee has provided this
information to the Council pursuant to paragraphs (10)(h), (10)(i),
(10)(j) or 10(k) above, the information may be used solely for the
purpose of determining whether to lay a charge of unbecoming, improper,
unprofessional or discreditable conduct, or to appoint a Preliminary
Inquiry Committee or a Competency Committee, or for the purpose of an
interview conducted by the Council or a Committee appointed by the
Council, and for no other purpose; or
b. For the purpose of preparing a report of a general nature by the
Council to the members of the College. Such information shall not
identify the physicians involved.
13. A witness before a discipline hearing committee or a competency
hearing committee is not liable to be asked and is not permitted to
answer any question or make any statement with respect to any proceeding
before a Practice Enhancement Committee, and may not be asked to
produce and is not permitted to produce any report, statement,
memorandum, recommendation, document, information, data or record that
is:
a. prepared exclusively for the use of or made by; or
b. used exclusively in the course of, or arising out of, any investigation by a Practice Enhancement Committee.
14. No report, statement, memorandum, recommendation, document,
information, data or record mentioned in paragraph (10)(m) is admissible
as evidence before a Discipline Hearing Committee or a Competency
Committee.
15. Paragraphs (10)(m) and (10)(n) do not apply to hearings before a
Discipline Hearing Committee on a charge that a physician is guilty of
unbecoming, improper, unprofessional or discreditable conduct for
failing or refusing to co-operate with the Practice Enhancement
Committee or for failing to comply with the provisions of these bylaws
pertaining to the Practice Enhancement Program.