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Midwifery Act, 1991
Loi de 1991 sur les sages-femmes

ONTARIO REGULATION 240/94

GENERAL

Note: This Regulation was revoked on November 5, 2012. (See: O. Reg. 335/12, ss. 16, 17)

Last amendment:  O. Reg. 335/12.

This Regulation is made in English only.

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CONTENTS

Part I (ss. 1-4) Revoked:  O. Reg. 28/01, s. 1.

Part II (s. 5) Revoked:  O. Reg. 28/01, s. 1.

PART III
QUALITY ASSURANCE

Definitions and Components of Program

6. In this Part,

“assessor” means an assessor appointed under section 81 of the Health Professions Procedural Code;

“Chair” means the Chair of the Quality Assurance Committee;

“Committee” means the Quality Assurance Committee;

“member” means a member who holds a general certificate of registration or a certificate of registration requiring supervision;

“practice group” means, in relation to a member, a group of one or more other members with whom the member is associated and, if the member is not associated with other members, means the member.  O. Reg. 184/99, s. 1.

7. (1) The quality assurance program of the College shall include the following components:

1. Provision of clinical information.

2. Continuing education and professional development.

3. Peer case review.

4. Quality of care evaluation.

5. Self-assessment.

6. Practice audits.

7. Remediation of behaviour and remarks of a sexual nature.

(2) The quality assurance program shall be administered by the Committee.

(3) The Chair may appoint a panel to carry out any of the powers or functions of the Committee under the Act.

(4) A panel shall consist of at least three people, at least one of whom shall be a person who is not a member and who is appointed to the Committee by the Lieutenant-Governor in Council.  O. Reg. 184/99, s. 1.

8. (1) Sections 9 to 19 do not apply to a member who has ceased to practise midwifery for at least one year.

(2) The Committee may, upon application, grant an exemption from any of the requirements of sections 9 to 19 to a member by reason of illness or maternity leave or in any other extenuating circumstances.  O. Reg. 184/99, s. 1.

Provision of Clinical Information

9. (1) Upon request by the Committee, a member shall provide the Committee with information relating to the care given by the member to clients. The information shall be in the form specified by the Committee.

(2) If the Committee so requests, the information provided under subsection (1) shall relate to care given to clients during a specified period of time.

(3) A member shall ensure that clients are not identified in the information provided under subsection (1).  O. Reg. 184/99, s. 1.

Continuing Education and Professional Development

10. (1) A member shall participate in continuing education and other professional development activities for the purpose of maintaining and enhancing the member’s knowledge, skills and judgment.

(2) A member shall maintain an annual record of his or her participation in continuing education and professional development activities and shall submit the record to the Committee on request.

(3) The record shall include,

(a) particulars of his or her learning needs as identified by the member; and

(b) the content, date, duration, location and, if applicable, the name of the sponsor of each continuing education and professional development activity engaged in by the member.

(4) The Committee may require the record to be maintained in a form provided by the Committee.

(5) The member shall retain records of continuing education and professional development activities for at least 10 years from the date the member participated in the activities.  O. Reg. 184/99, s. 1.

Peer Case Review

11. (1) A member shall participate in at least six peer case reviews in every 12-month period commencing January 1 of each year.

(2) In a peer case review, a group of at least four members belonging to at least two different practice groups meet to discuss clinical care of clients.

(3) A peer case review shall be conducted in accordance with College guidelines published by the College and distributed to members and shall include the following elements:

1. A presentation of a case history and of how the case was managed by one of the members participating in the review.

2. A discussion of the application of College regulations, standards, guidelines and policies to the case.

3. The observations and feedback of the participants.

(4) A member shall maintain an annual peer case review record in which the member records the names of the members who carried out each peer case review and the date and duration of each review.  The record shall be submitted to the Committee on request.

(5) A member shall keep the peer case review record for at least 10 years from the date the review was held.  O. Reg. 184/99, s. 1.

Quality of Care Evaluation

12. (1) A member shall provide every client with a quality of care evaluation form within six months of being discharged from care and request that the client complete the form and return it to the member’s practice group.

(2) The evaluation form shall not identify the client.

(3) A member shall make a record of any action taken in response to a client’s evaluation and shall submit the record to the College on request.

(4) The Committee may require that the quality of care evaluation form and the form of the record of action taken be in a form provided by the Committee.

(5) A member shall retain a completed evaluation form for at least 10 years from the date the evaluation form is returned to the member’s practice group.

(6) A member shall retain the record of action taken in response to a client’s evaluation for at least 10 years from the date the action was taken.  O. Reg. 184/99, s. 1.

Self-Assessment

13. (1) At the request of the Registrar, a member shall complete a self-assessment questionnaire provided by the Committee and return it to the College.

(2) A member who fails to return a completed self-assessment questionnaire to the College when requested to do so by the Registrar shall, if so required by the Committee, participate in a practice audit.  O. Reg. 184/99, s. 1.

Practice Audit

14. (1) Each year, the College shall select at random the names of members required to undergo a practice audit.

(2) A member shall undergo a practice audit by an assessor if his or her name is selected at random and the College may require a member to undergo a practice audit if the member has failed to return a completed self-assessment questionnaire under subsection 13 (2).  O. Reg. 184/99, s. 1.

15. A practice audit shall be conducted by an assessor and may include,

(a) requiring a member to provide the assessor with such forms and other documents used in the member’s practice;

(b) an examination of the member’s client records; and

(c) an interview with the member.  O. Reg. 184/99, s. 1.

16. (1) An assessor shall, within a period of time specified by the Committee, provide a written report of a practice audit to the Committee and to the member whose practice was the subject of the audit.

(2) The member whose practice was the subject of a practice audit may make written representations to the Committee within 14 days of receiving the written report of the practice audit.  O. Reg. 184/99, s. 1.

17. (1) After considering the report and any representations made by the member, the Committee may decide,

(a) that no action is required;

(b) subject to section 19, to require the member to undertake the remediation or other action specified by the Committee to correct any deficiency disclosed by the practice audit; or

(c) to refer the member to the Executive Committee.

(2) After the member has had an opportunity to undertake the remediation or other action specified, the Committee may require the member to undergo a follow-up practice audit.

(3) The Committee shall not require that a member undergo more than one follow-up practice audit.  O. Reg. 184/99, s. 1.

18. (1) Subject to section 19, the Committee may direct the Registrar to impose terms, conditions or limitations on a member’s certificate of registration for a specified period not exceeding six months if the member’s knowledge, skills and judgment are found to be unsatisfactory and,

(a) the member fails to undertake the remediation or other action specified by the Committee; or

(b) the member fails to successfully complete the remediation or other action specified by the Committee.

(2) If the Registrar imposes terms, conditions or limitations on a member’s certificate or registration for a specified period pursuant to a direction given by the Committee under subsection (1), the Committee may direct the Registrar to remove the terms, conditions or limitations before the end of the specified period if the Committee is satisfied that the deficiency has been remedied.  O. Reg. 184/99, s. 1.

19. If the Committee proposes to require a member to undertake remediation under section 17 or to direct the Registrar to impose terms, conditions or limitations on the member’s certificate of registration under section 18, the Committee shall give the member written notice of the proposal and at least 14 days from the receipt of the notice to make written representations to the Committee.  The Committee shall consider any representations made by the member before making a final decision under section 17 or 18.  O. Reg. 184/99, s. 1.

Remediation of Behaviour and Remarks of a Sexual Nature

20. Sections 21 to 24 apply to matters relating to sexual abuse as defined in clause 1 (3) (c) of the Health Professions Procedural Code that are referred to the Committee by,

(a) the Complaints Committee, pursuant to paragraph 4 of subsection 26 (2) of the Health Professions Procedural Code; and

(b) the Executive Committee, pursuant to section 79.1 of the Health Professions Procedural Code.  O. Reg. 184/99, s. 1.

21. (1) If a matter referred to in section 20 in respect of a member is referred to the Committee, the Committee shall require the member to undergo a psychological or other assessment to determine whether the member should undergo therapy, counselling, education or other specified measures.

(2) The person conducting the assessment shall provide a written report of the results of the assessment to the Committee and shall make such recommendations as he or she considers appropriate.

(3) The Committee shall give the member a copy of the report and recommendations together with a notice informing the member of the right to make a written submission respecting the recommendations in accordance with subsection 22 (2).

(4) After considering the report and recommendations and a submission made by the member, if any, the Committee may require the member to attend or participate in an education, counselling or therapy program or to take such other measures as may be specified by the Committee.

(5) If the member refuses to undergo an assessment as required under this section, to attend or participate in a program or to take any other measure specified by the Committee, the Committee may, subject to subsection 22 (3), direct the Registrar to impose specified terms, conditions or limitations on the member’s certificate of registration for a specified period of up to six months.  O. Reg. 184/99, s. 1.

22. (1) A member has the right to make a written submission to the Committee,

(a) before the Committee requires the member to attend or participate in a program or to take any other measure specified by the Committee under subsection 21 (4); and

(b) before the Committee makes a direction under subsection 21 (5).

(2) The member shall be given at least 14 days from the day the member receives the report and recommendations under subsection 21 (3) to make written submissions to the Committee.

(3) The Committee shall give the member notice of its intention to make a direction under subsection 21 (5) and at least 14 days from the date the member receives the notice to make written submissions to the Committee.  O. Reg. 184/99, s. 1.

23. The Committee shall direct the Registrar to remove the terms, conditions or limitations imposed on the member’s certificate of registration under subsection 21 (5) before the end of the specified period if the Committee is satisfied that the terms, conditions or limitations are no longer needed.  O. Reg. 184/99, s. 1.

24. If a term, condition or limitation has been imposed on a member’s certificate of registration for a specified period under subsection 21 (5) and, at the end of the period, the member continues to refuse to undergo an assessment, to attend or participate in a program or to take any other measure specified by the Committee, the Committee shall refer the matter to the Executive Committee.  O. Reg. 184/99, s. 1.

PART IV
NOTICE OF OPEN MEETINGS AND HEARINGS

Council Meetings

25. (1) The Registrar shall ensure that notice of every council meeting that is required to be open to the public under the Act is given in accordance with this section.

(2) The notice shall be published no less than 14 days before the date of the meeting in a daily newspaper of general circulation throughout Ontario.

(3) The notice shall be in English and French.

(4) The notice shall include the intended date, time and place of the meeting and a statement of the purpose of the meeting.

(5) The Registrar shall give a copy of the notice to every person who requests it.  O. Reg. 184/99, s. 1.

Discipline Committee Hearings

26. (1) The Registrar shall ensure that information concerning a hearing by a panel of the Discipline Committee respecting allegations of professional misconduct or incompetence by a member is given to every person who requests it,

(a) at least 30 days before the intended date of the hearing, if possible; or

(b) for requests made less than 30 days before the meeting, as soon as reasonably possible after the request is made.

(2) The information shall be available in English and French.

(3) The information shall include,

(a) the name of the member against whom the allegations have been made;

(b) the member’s principal place of practice;

(c) the intended date, time and place of the hearing; and

(d) a statement of the purpose of the hearing.  O. Reg. 184/99, s. 1.