What to Expect from Your First CPSO Peer Assessment Dr. Ian Cowan, MD, CCFP
DISCLOSURE No conflict of interest declared
OBJECTIVES 1. Explain the selection and expectations of a College of Physicians and Surgeons (CPSO) Peer Assessment; 2. Identify College requirements on clinical documentation of specific assessed conditions as per the Peer Assessment Handbook; 3. The steps following a Peer Assessment – both good & bad!
INTRODUCTION Like Death and Taxes, you will eventually have a CPSO Peer Assessment! A Peer Assessment is done by a physician with a similar practice make-up to you The aim is education, not discipline
Types of Family Medicine Peer Assessment Random • CPSO hopes to assess each physician every 5-10 years Special Circumstances • Limited licence • FMG Age > 70 years Reassessment • by same or different physician New to Practice (< 2 years)
NOTIFICATION • Letter from CPSO notifying of selection with instructions and link to CPSO website for more detailed information; • Name of Assessor; • Usually 2-3 month notice; • Assessor will contact you to confirm instructions & negotiate a date for the assessment
SPECIFICS • Review of 15-20 charts selected on single or two office days • We select a date for the chart review 3-6 months prior to your letter from CPSO notifying you of the peer assessment • No hospital or LTC charts; will look at WIC charts • Review of specific charts (5 each): • Mental health • Pre-natals • Chronic Opiate Use • Periodic Health Exams • Well Baby/Child Visits • Diabetes
HOW IT STARTS… • Introduction and expectations • Quick review of EMR system and any special or add-on programmes • Tour of your office looking at equipment, cleanliness, organization, emergency equipment, drug samples & staff introduction • Assessment usually takes 4-5 hours • 30 min initial meeting • 4 hr chart review – you can see patients but should be available to answer questions or clarify records • 30 min wrap-up
ARE YOUR CHARTS UP TO STANDARD? • Current & complete Cumulative Patient Profile • Allergies listed • Chronic conditions and surgical history • Chronic & episodic medications listed • Preventative Medicine interventions listed when completed or pending (colon cancer screening, PAP, Mammogram, Bone Density +/- PSA) • Immunizations – both child & adult • SOAP Note format for most visits • Look for logical flow of notes, appropriate history & exam including salient negatives • Commit to a diagnosis or differential diagnosis • Make a plan including investigations, medications and note follow-up
WHERE MDs GO WRONG! • Could a locum or colleague step in and understand your note, decision making process and plan – look at your note when done & think of this! • S OAP – not enough history to define the problem including salient negatives • S O AP – record you physical exam findings; more importantly do a physical exam ! This is omitted more often than you think! • SO A P – Commit to a diagnosis or DDx – many don’t • SOA P – if you start a new medication, discuss/record S/E’s and risk benefit especially if a new long-term medication; note follow-up
MEDICATION PITFALLS • If you start an ACE-I or ARB – check lytes & renal function within a few weeks • Off label use of drug or excess dosages – write a comment in chart • When you prescribe DOAC’s – keep an eye on renal function. Suggest a max 6 month prescription only then check renal function to confirm use & dose still appropriate • Remember our nemesis “QT” – check QT when prescribing one or multiple meds that can influence QT • Remember & try to use the Sick Day Meds Sheet
MENTAL HEALTH CHARTING • Ask about & record presence/absence of suicidality/homicidality at each mental health visit • Consider use of objective scales for depression at each visit (PHQ 9, HAMD, etc.) – not mandatory but recommended • Close follow-up of depression patient. Bring them back quickly (ie: 2 weeks) and adjust doses, change or augment to get to remission ASAP • Use and record the use of local mental health providers • Record start & stop times for “K” code billings • If you do psychotherapy, make sure you have the training and follow a template
DIABETES CHARTING • Flow sheets a must ! Should include serial HgbA1c, LDL, BP, renal function, ACR, etc. • Don’t forget to document eye exams & do periodic monofilament testing of the feet • Review the CDA guidelines – there are more choices than just Metformin, suflonylureas & insulin; this is the sole armamentarium of many MD’s ! • We do look at overall diabetes control so you should too!
OPIATE PITFALLS • Big concern these days so be careful & cautious • Use Opioid Screening Tool before starting long-term opiates • Use Opioid Agreement with copy on chart & with patient • Use frequent, small volume prescribing • Consider mandatory blister packs for opiates to aide compliance and pill counts; do pill counts at visits periodically • Random Drug Screens – do them & do them often ! • Use Brief Pain Inventory at each pain visit • Read the new Opiate Guidelines and get your Opioid Practice Assessment
PREVENTITIVE MEDICINE PITFALLS • We do look for PAP’s, colon cancer screening, mammograms, bone density. +/- PSA (or discussion) • Adult Immunizations are under close scrutiny now. Remember Flu shots, Pneumovax, Td & Varicella • Don’t forget to mention/offer Gardasil 9, Prevnar 13, Bexsero & travel vaccines when appropriate; record that you discussed them
GENERAL OFFICE MEDICINE PITALLS 1 • Have a system for your INR notifications & record instructions for repeat testing • If you or staff give telephone advice, record in a note on the patient’s chart • For significant lab or Xray abnormalities, make a chart note on the action you are taking and follow-up required • We are mandated to look at equipment, drug samples and safety issues • Emergency Equipment – if you do immunizations and/or allergy shots, have the appropriate emergency drugs & equipment. We will check emergency drug expiration dates
GENERAL OFFICE MEDICINE PITALLS 2 Minor Surgery • Consider use of single use vials (ie: Lidocaine) • Consider disposable single use equipment (ie: suture kits) • Thanks to Public Health Ontario (PHO) and new WHIMS regulations our life in the office will get more difficult. They are recommending against office autoclaving unless you have a horrendous number of checks & balances in place. These rules have not been enacted yet. For a good read – look at the 120 page document “Infection Control in the Physician’s Office” on the PHO website !!
ACTIONS AFTER PEER ASSESSMENT Assessor sends report to CPSO & reviewed by staff: No Concerns (70% of assessments) – letter sent to you with congrats and copy of report Urgent Safety Concerns (<1%) – immediate CPSO review and action Mild & Moderate (Non-safety issues) (30%) – review by CPSO Committee with follow-up actions initiated. This could include: Interview with the committee; and/or Direction to correct deficiencies then re-assessment by same or different assessor (your choice); usually in 1-2 yrs; If you fail two assessments and require third, CPSO will bill you for the cost of the third assessment.
REFLECTIONS ON A PEER ASSESSMENT • Assessor will help you improve your practice and documentation skills • Most of us have done dozens of assessments and can pass on some good suggestions • EMR’s do not guarantee good records – remember “junk in, junk out” • Complete your records so another physician could step in and take over without any angst • You want a Peer MD doing your assessment, not a non- MD assessor appointed by the College or MOH !
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