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.

Scope

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

Policy

All physician extender programs must adhere to the College policy for Physician Extender Programs².

1. Objectives of the Accreditation Process

The College surveys, evaluates, and accredits all physician extender programs in the province of Nova Scotia.  The objectives of the accreditation process are to:

1. ensure the quality of physician extender programs, consistent with the College requirements for such programs;
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.

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 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 on-site surveys;
3. reviews the findings of the surveys;
4. determines the accreditation status of each physician extender program surveyed; and,
5. reports at least annually to Council on its accreditation activities and brings forward, as necessary, any recommendations for change to accreditation policies and procedures to the Registration Policy Committee; and,
6. will maintain a current list of all accredited physician extender programs.

3. The Accreditation Process

The accreditation 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 physician extender program.

All costs related to the accreditation of physician extender programs must be borne by the program.  Accreditation surveys must be carried out by a trained accreditor approved by the College.

1. Regular Accreditation Surveys

1. Regular accreditation surveys will be conducted within the first 12 months of the start of a physician extender 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 the on-site accreditation review;
3. The accreditor examines the documentation and conducts interviews with relevant representatives from the program, which may include:
   • the senior administrative officer of the institution responsible for the oversight of the institution’s physician extender programs
   • the department or division head,
   • the physician extender program director,
   • a selection of supervising physicians,
   • physician extenders, 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 accreditor meets with the senior administrative officer and the physician extender program director at the conclusion of the survey and provides an overview of the accreditation survey findings;
6. The accreditor submits a written report to the Deputy Registrar of the findings of the accreditation survey;
7. The Registration Committee reviews the accreditation survey findings and decides upon the accreditation status of each physician extender 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 the physician extender program director.

2. Ad hoc Accreditation Survey

The Registration Committee may, at its discretion, direct that an ad hoc accreditation survey of a physician extender program be conducted when it has reason to believe that there are significant concerns about the quality or conduct of the program.

4. 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 survey, 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 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 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 and the 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