Practice Enhancement Program Committee

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.


16. The Practice Enhancement Committee shall report to the Council and the Saskatchewan Medical Association on its activities and programs of assessment at such times and in such manner as the Council may from time to time direct.

17. The Practice Enhancement Committee will select the members of the College to be assessed and in doing so will endeavour to have due regard for the distribution of medical practitioners in the province and the differences in practices and specialties to the end that the benefits of the activities of the Practice Enhancement Committee may be fairly extended to the public and the members of the College throughout the province.

18. If, during the course of an assessment or assessments, the Practice Enhancement Committee identifies concerns of a systemic nature that, in the opinion of the Committee:
 a. should be remedied; and
 b. are not limited to the practice of the physician being assessed the Committee may report their concerns to the individuals or organizations that, in the Committee's opinion, have the responsibility to remedy such concerns.

19. If a report pursuant to paragraph (r) is made to a physician, or to more than one physician, the Practice Enhancement Committee may:
 a. meet with the physician(s);
 b. prepare recommendations to the physician(s) to address the concerns identified by the Practice Enhancement Committee;
 c. arrange for a review, at some future time, to determine if the concerns of a systemic nature identified by the Committee have been rectified.

20. Where the Committee has formed the opinion that the physician(s) has refused or neglected to remedy the concerns of a systemic nature identified by the Committee pursuant to paragraph (r) the Committee may refer that matter to the College and the provisions of paragraph (i) through (o) above apply, with such changes as may be necessary.

21. If a report pursuant to paragraph (r) is made to a person who is not a physician, or to an organization, the Practice Enhancement Committee may:
 a. meet with such person or persons as the Committee think advisable;
 b. prepare recommendations to the person or persons to address the concerns identified by the Practice Enhancement Committee;
 c. arrange for a review, at some future time, to determine if the concerns of a systemic nature identified by the Committee have been rectified.

22. The Committee may also report the matter to the Minister of Health if the report pertains to:
 a. a regional health authority or a health care organization within the meaning of The Regional Health Services Act, the Saskatchewan Cancer Foundation, or a person or organization that provides health services pursuant to an agreement with the Minister of Health, or
 b. any other persons or organization, on an informational basis.

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