Guideline for the Conduct of Return to Practice Assessments
Under Section 16 (1) of the Medical Practitioners’ Regulations:
Before returning to clinical practice after an absence of 3 years or longer, a person must
- notify the Registrar of their intention to return to clinical practice in writing before they return to clinical practice; and
- successfully complete a competence assessment as determined by the Registrar.
The return to practice assessment is conducted under the provisions for High Level Supervision as laid out in the “CPSNS Supervision Framework – Responsibilities and Outline by Level”. For the purpose of this document, the terms Assessor and Supervisor are used interchangeably.
Governing Policy: Policy on Return to Practice Assessments
Physicians seeking an assessment for re-entry to practice must submit a written application to the Registrar. Applications will be considered only from physicians who:
- Upon successful completion of the assessment, will be eligible for a Full licence or Restricted licence in Nova Scotia.
- Provide evidence in the form of a written statement from either the Nova Scotia Health Authority or Isaak Walton Killam (IWK) Health Centre that they have employment or a position in a practice within the province and that they will be credentialed upon successful completion of the assessment.
- Have a proposed scope of practice for which assessment capacity exists in Nova Scotia;
- Allowing for the discretion of the Registrar, have been previously licensed in and are currently resident in the province of Nova Scotia; and
- Pay a non-refundable application fee as set by the College.
Approval and Costs
Approval to enter practice re-entry assessment will be contingent upon:
- Agreement between the CPSNS Registration Committee and physician on an acceptable scope of practice and assessment;
- Identification of an assessment site and supervisor(s) acceptable to the CPSNS;
- Signed supervisory agreements from all parties;
- Privileging by the relevant health authority and zone;
- Evidence of medical malpractice insurance (CMPA or equivalent); and
- Payment of costs as outlined below.
The requesting physician will be responsible for paying all costs of the assessment, including but not limited to:
- Application and licensure fees*
- Malpractice insurance
- Site licence fees for Electronic Medical Records, if applicable
- Any fee levied by the supervising/assessing physician(s)*
- A monthly administration fee payable to the CPSNS*
* payable in advance to CPSNS
Agreement on the part of a Supervisor (or team of Supervisors) to conduct a return-to-practice assessment entails a major commitment in terms of time and responsibility. For most supervisors, the assessment will lie outside their usual duties and therefore increase workload and/or reduce clinical income. Nationally, supervision fees for similar purposes (e.g. NAC-PRA) range from $1000-1500 per week. It is the College’s position that compensation of a Supervisor is fair and justified for the purpose of ensuring comprehensive oversight and reporting.
In all cases, supervisory fees will be paid in advance to the CPSNS, who will then be responsible for remunerating the Supervisor(s). The agreement to provide supervision is made only between the CPSNS and the Supervising physician(s), No direct financial obligation or relationship may exist between the Supervisor(s) and the assessed physician.
Scope of Assessment
The scope of the re-entry assessment will be determined by the Registration Committee in consultation with the CPSNS Physician Performance Department and from information provided by the subject physician and physicians of the same specialty, taking into account the following:
- The physician’s intended and reasonably anticipated future scope of practice.
- The needs of the community to be served.
- Available resources for assessment (expertise, time, opportunity).
- Placing the fewest possible explicit conditions on the physician’s licence, recognizing that change-in-scope of practice provisions are always relevant.
Specific major exclusions of scope will in most cases be specified in advance of the assessment, and will constitute either implicit or explicit restrictions on the physician’s subsequent scope of practice.
In some circumstances, additional explicit exclusions to the physician’s scope of practice may be made as a result of the assessment, for example:
- If there were insufficient opportunities during the assessment to make a judgement of competence within a well-defined and limited aspect of overall practice.
- If the physician failed to demonstrate competence within a well-defined and limited aspect of overall practice.
Selection of Supervisor/Assessor(s)
Assessments are more likely to be valid and reliable when conducted by multiple experienced assessors who have a clear understanding of the expected standard. Furthermore, an adequate number and variety of assessment opportunities is essential to reaching a defensible conclusion regarding competence to re-enter practice.
Approval of supervisor/assessor(s) and practice location will ordinarily be made by the Director of the Physician Performance Department. In addition to the general requirements and characteristics of an acceptable supervisor/assessor, as laid out in the Guiding Principles for College-directed Clinical Supervision, a number of additional factors will be considered, including:
- The availability of experienced and available clinical supervisor/assessor(s). Preference will usually be given to locations with more than one assessor.
- The availability of a suitable number of variety of clinical experiences within the anticipated scope of practice.
- The ability of the supervisor/assessor(s) to provide an unbiased assessment of competence (i.e. absent conflict of interest).
- Geographic location acceptable to the assessed physician and the College.
- Reasonable cost.
Although the CPSNS will make reasonable efforts to secure a return-to-practice assessment, it is not possible to guarantee the availability of an appropriate assessment within the province of Nova Scotia.
Responsibilities of the Supervisor/Assessor(s)
The return-to-practice assessment is conducted under the provisions for High Level Clinical Supervision. The general responsibilities and obligations laid out in these documents apply to return-to-practice assessments.
Assessor/Supervisor(s) must be familiar with and adhere to the Basis of Immediate Reports to the College section of the Guiding Principles for College-directed Clinical Supervision.
The Assessor/Supervisor(s) will, in all cases, be the Most Responsible Physician (MRP) for any return-to-practice assessment, regardless of the assessed physician’s licence type.
As such, the Assessor/Supervisor takes responsibility for appropriate oversight of all activities, including but not limited to clinical assessments, investigation, diagnosis, management and documentation. The Supervisor(s) is given discretion to determine the circumstances under which direct (i.e. observation/assistance) versus indirect (review and discussion) oversight are used. Typically, this will be determined by the clinical context and the assessed physician’s demonstrated abilities.
Specific additional requirements will be laid out in the detailed Supervision Plan, including:
- The clinical context(s) in which supervision/assessment will take place.
- The range of skills, knowledge and attitudes that are to be assessed.
- The nature and approximate frequency of assessment activities.
- The nature and frequency of reports to the College.
Responsibilities of the Assessed Physician
The return-to-practice assessment is conducted under the provisions for High Level Clinical Supervision. The general responsibilities and obligations as laid out in College supervision documents apply to return-to-practice assessments.
Nature of Assessment
Although the primary purpose of the return-to-practice assessment is for the physician to demonstrate competence in their intended scope, it is assumed that there will be some element of re-training, particularly in circumstances where the physician has been absent from practice for an extended period.
In all circumstances, there will be an expectation that the practitioner undertake comprehensive professional development activities, both in advance of and in conjunction with the re-entry assessment. Unless otherwise specified, the re-training responsibilities of the clinical supervisor(s) will be limited to:
- provision of feedback for improvement based on the participation in real or simulated clinical activities;
- clinical teaching around real or simulated cases; and
- guidance regarding professional development resources and activities.
A determination of suitability for independent practice is only valid and reliable when supported by a sufficient number and variety of documented discrete assessments. Selection of assessment opportunities and methods must be guided by the supervision plan and intended scope of practice. As the assessment proceeds, the supervisor(s) must adapt their plan to ensure that all essential competencies have been assessed.
In most cases, assessment will be conducted through direct or indirect observation in the clinical environment. Direct observation is self-explanatory. Indirect observation may include the review and discussion of clinical cases or records. Documentation of direct and indirect assessments will in most cases be done using:
- Field notes
- Direct Observation Forms (Clinical or procedural)
Feedback may be obtained from physician colleagues, other medical personnel or patients and documented using:
- Structured forms “Medical Colleague Interview” tool
- Field notes
Where capacity exists, (i.e. in an established teaching center), additional methods of assessment, such as simulation or semi-structured oral examinations, may be used.
In the context of a limited clinical assessment, it is impossible to ensure that the full range of foreseeable clinical conditions will be encountered and assessed. Instead, experiences will be chosen for the purpose of providing a representative sample of clinical encounters, from which a determination of competence may be reasonably made.
Where circumstances and resources allow, non-clinical methods of assessment (e.g. technical simulation, simulated patient encounters, oral scenarios, etc) may be employed to extend the scope of assessment or address essential but uncommonly encountered clinical scenarios.
Duration of Assessment
Practice Re-entry Assessments will typically be of at least three months duration. However, in determining the exact duration of any assessment, the following factors will be considered:
- Length of absence from clinical care
- Nature and scope of any interval practice
- Length and nature of practice prior to absence
- Intended scope of practice
- Demonstrated competence during the assessment
The planned and ultimate duration of any assessment will be determined by the CPSNS Registration Committee.
If, after an assessment period of at least four weeks, the Supervisor/Assessor(s) are of the firm opinion that formal retraining is required to ensure a physician’s clinical competence, the assessment may be discontinued with the College’s agreement and the physician will be advised to seek additional training.
In general, the standard of performance applied in a Return-to-Practice Assessment will be that of a competent specialist physician, ready to enter practice. In this respect, a competent final year residency trainee, ready to enter independent practice, is the most useful frame of reference.
The specific objectives and standards of performance applied will be those of the respective certifying college (CCFP or RCPSC).
Physicians are additionally expected to meet the professional standards of the CPSNS.
The nature and frequency of reporting will be laid out in the Assessment Plan. Ordinarily, a performance summary accompanied by supporting documents (i.e. field notes) will be required at least once per month.
At the end of the assessment period, the supervising physician(s) will be required to make one of the following recommendations to the College:
- That the physician has demonstrated competence in the full scope of practice for which the assessment was conducted; or
- That the physician has not yet demonstrated competence in the full scope of practice for which the assessment was conducted, and requires either further training or further assessment in the following areas (listed).
A determination of suitability for licensure will rest with the Registration Committee, with the option of consultation or appeal to the Registration Appeals Committee.
If it is determined that further training or assessment is required, responsibility will rest with the assessed physician to obtain and fund such opportunities.
In some circumstances, the College will require a follow-up in-practice assessment of the physician within twelve months of return to independent practice.
This assessment will take place in the physician’s practice using methods and tools appropriate to such purposes including, but not limited to:
- Facility inspection
- Chart review and Chart-stimulated Recall
- Direct observation of clinical care or procedures
- Structured interviews with colleagues.
The follow-up assessment will be conducted at the assessed physician’s expense.
Significant concerns raised during the follow-up assessment will be referred to the Registration Committee for consideration.
Assessment Committee, Council
March 8, 2019