Clinical Assistant Program – Accreditation

Policy

There must be institutional oversight for all clinical assistant programs within the institution with a senior administrative officer (e.g. VP of Medicine) identified and responsible for the oversight. There must be a central record of all clinical assistants, including their qualifications, credentials, and copies of evaluation reports, procedure certification, and satisfaction surveys. These centrally held documents must be available at the time of program survey by the College and at other times upon written requests by the College.

There must be a clinical assistant program director appointed. There must be evidence that the responsible senior administrative officer reviews, at least annually, with each clinical assistant program director the conduct of the department’s Clinical Assistant Program.

1.Objectives of the Accreditation Process
The College of Physicians and Surgeons of Nova Scotia (College) surveys, evaluates, and accredits all clinical assistant programs in the province of Nova Scotia. The accreditation process has as its major objectives:

1. to ensure the quality of clinical assistant programs, consistent with the College requirements for such programs;
2. to provide a means for objective assessment of clinical assistant programs; and
3. to provide guidance to institutions in the development and implementation of clinical assistant programs.

2.Registration Committee
The Registration Committee of the College has been delegated by the Council of the College to oversee the process of the accreditation of clinical assistant programs. In this regard the Registration Committee:

1. recommends to Council the policies, requirements and process relating to the accreditation of clinical assistant programs;
2. arranges periodic reviews of clinical assistant programs through required documentation and on-site surveys;
3. reviews the findings of the surveys;
4. determines the accreditation status of each clinical assistant program surveyed; and,
5. reports at least annually to Council on its accreditation policies and procedures; and,
6. will maintain a current list of all accredited clinical assistant programs.

3.Sponsorship of Clinical Assistant Program
The College will consider for accreditation only those clinical assistant programs sponsored and approved by institutions designated by the College.

4.The Accreditation Process
The process is based upon a system of provision of required documentation and periodic on-site surveys in order to provide to the Registration Committee the information necessary to inform its decision about the accreditation status of a clinical assistant program.

Accreditation of clinical assistant programs sponsored by approved health care organizations in Nova Scotia must be cost neutral to the College. Accreditation surveys must be carried out by a trained accreditor mutually acceptable to the College and the sponsoring health care organization.

A. Regular Surveys 

1. regular surveys will be conducted within the first 12 months of the start of a clinical assistant program and every four years thereafter unless determined otherwise by the Registration Committee;
2. the institution and the programs provide the required documentation prior to survey;
3. the surveyor examines the documentation and interviews the senior administrative officer of the institution responsible for the oversight of the institution’s clinical assistant programs, the department/division heads, the clinical assistant program director, a selection of supervising physicians, clinical assistant, and other institution staff as appropriate;
4. evaluate the adequacy of the continuing professional development and the means by which it is tracked and recorded;
5. the surveyor meets with the senior administrative officer and the clinical assistant program director at the conclusion of the survey and provides an overview of the survey findings;
6. the surveyor submits a written report to the Deputy Registrar of the findings of the survey;
7. the Registration Committee reviews the survey findings and decides upon the accreditation status of each clinical assistant program surveyed; 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 clinical assistant program director.

B. Special Surveys

The Registration Committee may, at its discretion, direct that a special survey of a clinical assistant program be conducted when it has reason to believe that there are significant concerns about the quality or conduct of the program.

5.Categories of Accreditation 

1. Approval – The program has met or substantially met all of the requirements with no major deficit identified requiring follow-up by the Registration Committee. It is assumed that prior to the next survey the institution/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 survey, it is granted provisional approval. The follow-up is at the discretion of the Registration Committee and may require documentation and/or a repeat on-site survey. If major deficiencies are not addressed and resolved the Registration Committee may recommend to Council that accreditation of the Clinical Assistant Program be withdrawn.
3. Withdrawal of Accreditation – A decision by the College’s Council to withdraw accreditation is effective immediately and the institution and the program are obliged to make the necessary internal arrangements in a timely fashion to cease operation of the program.