Physician extender programs – accreditation

Preamble

All physician extender programs in Nova Scotia are accredited by the College of Physicians and Surgeons of Nova Scotia (the College).

Section 8 (1)(f) of the Medical Act¹ gives the College authority to oversee and approve programs which permit others to engage in designated aspects of the practice of medicine, including provisions for supervision or other forms of accountability.

Purpose

This policy describes the College’s objectives, process and potential outcomes for accreditation of physician extender programs. All physician extender programs must adhere to the College policy for Physician Extender Programs.²

The objectives of the accreditation process are to:

1. ensure the quality of physician extender programs is consistent with the College requirements;
2. provide a means for objective assessment of physician extender programs; and
3. provide guidance to institutions in the development and implementation of physician extender programs.

Scope

This policy applies to all physician extender programs in Nova Scotia.

Policy

1. Registration Committee
   The Registration Committee has been delegated by Council to oversee the process of the accreditation of physician extender programs. In this regard the Registration Committee:
   1. recommends to the Registration Policy Committee the requirements and process relating to the accreditation of physician extender programs;
   2. arranges periodic reviews of physician extender programs through required documentation and virtual reviews;
   3. reviews the findings and determines the accreditation status of each physician extender program;
   4. reports at least annually to Council on its accreditation activities; and
   5. will maintain a current list of all accredited physician extender programs.
2. The Accreditation Process
   The accreditation process is based upon a system of provision of required documentation and periodic reviews to provide the Registration Committee the information necessary to inform its decision. ​All costs related to the accreditation of physician extender programs must be borne by the program. Accreditation reviews must be carried out by a trained accreditor approved by the College.
   1. Regular accreditation reviews
      1. Regular accreditation reviews will be conducted within the first 12 months of the start of a physician extender program and every five years thereafter unless determined otherwise by the Registration Committee;
      2. The institution and the programs provide the required documentation prior to the accreditation review;
      3. The accreditor examines the documentation and conducts interviews with relevant representatives from the program, which may include:
         • the physician extender program director,
         • a selection of supervising physicians,
         • the physician extenders, and
         • other institution staff as appropriate.
      4. Evaluate the adequacy of each registrant's continuing professional development and the means by which it is tracked and recorded;
      5. The accreditor meets with the physician extender program director at the conclusion of the review and provides an overview of the accreditation findings;
      6. The accreditor submits a written report to the College of the findings of the accreditation review;
      7. The Registration Committee reviews the accreditation findings and decides upon the accreditation status of each physician extender program; and
      8. The written report and the decision of the Registration Committee and any recommendations are conveyed in writing to the senior administrative officer and to the physician extender program director.
   2. Ad hoc accreditation review
      The Registration Committee may, at its discretion, direct that an ad hoc accreditation review be conducted at any time it has reason to believe that there are significant concerns about the quality or conduct of the program.
3. Categories of Accreditation
   1. Approval
      The program has met the requirements with no major deficit identified requiring follow-up by the Registration Committee. It is assumed that prior to the next accreditation review, the facility/program will have corrected any deficiency identified.
   2. Provisional approval
      When a program is considered to have major weaknesses that require formal follow-up before the next regular review, it is granted provisional approval. The follow-up is at the discretion of the Registration Committee and may require documentation and/or a repeat review. If major deficiencies are not addressed and resolved, the Registration Committee may recommend to Council that the accreditation of the physician extender program be withdrawn.
   3. Withdrawal of accreditation
      A decision by the College’s Council to withdraw accreditation is effective immediately and the facility/program are obliged to make the necessary internal arrangements in a timely fashion to cease operation of the program.

Resources

1. Nova Scotia Medical Act
2. Physician Extender Programs