CPSO’s Quality Improvement Program

Earn CPD credits while also making things better for you and your patients

Physicians are natural quality improvers. Every day you take steps to make things better for you and your patients. The CPSO’s Quality Improvement (QI) Program is a way to formalize these activities and earn yourself numerous CPD credits in the process.

About the program

Once every five years, the CPSO selects physicians to complete quality requirements, which were previously limited to Peer and Practice Assessments. In 2020, the CPSO launched its QI Program as an alternative to peer assessment for members under 70 years of age. The first cycle of the QI Program runs from 2020 to 2025. Details of the next cycle will be available in late 2024. 

If you have been invited to participate in the QI Program, you still have the option to have a peer assessment instead, which involves a peer assessor from the CPSO visiting you to assess your practice. However, most physicians who have experienced both found peer assessment to be more onerous than the new QI Program.

The QI Program has two streams:

  • QI for Individuals
  • QI Partnership for Hospitals (for hospital-based physicians)

Physicians participating in QI for Individuals have the option of completing the program on their own or as part of a group. A CPSO member who has been invited to QI for Individuals can, in turn, invite up to six of their peers to form a QI Group, even if the peers have not yet received their own QI invitation from CPSO. Successful completion of the program allows all Group members to fulfil their CPSO quality requirements for five years. If physicians are unsuccessful in completing the QI Program, they will be required to complete a peer assessment.

Learn more about the QI Partnership for Individuals.

Learn more about the QI Partnership for Hospitals (for hospital-based physicians).

How much time will it take?

The total time commitment to complete the QI for Individuals Program depends on the individual, as well as the quality of data in their EMR or paper charts and the support staff they may have to help access this data, but typically is nine to 12 hours. Participants can determine what works best for their schedule. The program lends itself to being completed in sections at a time.

What to do when you are selected

Go online through your CPSO member portal to choose a completion date. There are a limited number of spots available for each date, on a first-come, first-served basis.

Once you complete and submit the final activity, be aware that it will not be reviewed by CPSO until after your selected completion date.

QI for Individuals

Your first task is to complete the QI Survey, an online questionnaire that tells the CPSO who you are and what kind of work you do. This will take five to 10 minutes to complete.

Next come the three activities housed in the CPSO’s Learning Management System.

  1. Practice profile: This activity is an online self-assessment that highlights factors that can affect physician performance. This will take 45-60 minutes to complete
  2. Self-guided chart review: This activity involves choosing five patient records that reflect your practice/work, and reviewing them using a checklist that is provided. This allows you to assess the quality of your records. This will take 60-90 minutes to complete. Although not required, the CPSO encourages you to share your reflections on the Self-Guided Chart Review with a trusted peer, such as a mentor, a physician colleague or an allied health professional colleague. Physicians who have completed the QI Program have reported that consulting with a trusted peer helped them to generate ideas for improvement
  3. Data-driven QI: This activity assists you in assessing and collecting your own practice-level data. The time to complete this activity varies depending on the data source you choose

The information you enter during these activities and the accompanying reflections are documented for your own learning and self-reflection. This content is not submitted to the CPSO and cannot be accessed by the CPSO.

Finally, you will complete your Practice Improvement Plan, which is submitted to the CPSO for review. Your completed Practice Improvement Plan will be reviewed by a QI coach at the CPSO.

If you are working as a group 

If you are working as a group to complete the QI for Individuals stream, complete the initial activities on your own, then work with your Group to discuss the activities and develop a Group Practice Improvement Plan.

How to complete the Practice Improvement Plan

The Practice Improvement Plan is where you identify your strengths as a physician and your opportunities for improvement. Doing so will help you generate improvement ideas that can be expressed as goals for improvement using the SMART criteria.

CPSO provides a Practice Improvement Plan template, available through your CPSO portal, which contains questions to guide you.

QI ideas

Find improvement ideas to try, based on Choosing Wisely Canada.

Quality Improvement (QI) is a philosophy or an attitude about how to make things better. It involves identifying something you would like to improve, making a change and then measuring an outcome to find out if your change was successful.

If at any time during this process you have questions, you can contact the CPSO’s Quality Improvement team. You can call 416-967-2648/1-800-268-7096 ext. 648, email, or use the messages tab in your member portal.

If you have circumstances that currently prevent you from completing the QI Program, you can ask to defer your participation. To request a deferral, contact the CPSO’s QI team.

Steps for completing the Practice Improvement Plan

The Practice Improvement Plan template will ask you to identify your strengths and areas for improvement, which could include:

  • A specific aspect of patient care or management
  • Approach to continuing professional development
  • Practice management
  • Record keeping
  • Approach to communicating with patients
  • Accessing peer support
  • Self-care and well-being

When thinking about your improvement goals, consider:

  • What are you passionate about in your work environment?
  • What is particularly relevant to your patient population? Consider equity, diversity and inclusion. For example, are there particular cohorts of patients who are receiving less equitable care?

Resources to help you identify your strengths and areas for improvement could include personal observations about your own practice, EMR data and reports, as well as external reports about your practice patterns, such as MyPractice Reports from Ontario Health.

  • The Practice Improvement Plan template will prompt you to develop your goals in a way that meets the SMART criteria for goal-setting
  • The SMART framework can help to make ideas actionable

  • One of your goals should be related to patient care/your work, and the other can be related to your own wellness and self-care
  • For each goal, describe the baseline (current state), the planned intervention(s), and the outcome measures (future state)

Patient care goals

You can refer to your Practice Profile, Self-Guided Chart Review and Data-Driven Quality Improvement activities to help you identify gaps in your practice and areas for improvement related to patient care. As you review these activities with a trusted peer, are there any gaps that stand out?

For example:

  • A physician who identified being in solo practice as a risk factor for isolation could develop an improvement goal around increasing peer support
  • A physician who identified gaps in record keeping from their Self-Guided Chart Review could develop an improvement goal to address these gaps

Data sources to help you identify patient care goals can include:

Observations about your own practice

Many physicians do not realize that they have access to a lot of practice-level data just by observing their own practice.

For example, a psychotherapist, who noticed that 50 per cent of therapy sessions finished late, could develop an improvement goal around finishing on time in at least 95 per cent of sessions.

EMR data and reports

You can use reports from your EMR to help you to identify areas for improvement. If you do not have an EMR, you can use your billing data.

For example, you could identify all patients living with diabetes in your practice and structure an improvement goal after assessing how many of them have seen an optometrist in the last year.

For support on how to maximize the value of your EMR, reach out to the OMD Advisory Service.

External reports

Those in primary care have many sources of data available to them. Many physicians in other specialties also have access to some of these reports:

MyPractice Reports (OH)

Care Canvas (Family and Community Medicine, University of Toronto)

  • This dashboard is designed for family physicians and primary care teams and is available to all physicians using Telus Practice Solutions, Accuro or OSCAR EMRs

Screening Activity Report (SAR from Cancer Care Ontario)

  • This online interactive report is available to primary care physicians who practice as part of a patient enrollment model, or to non-patient enrollment model physicians who practice in the Sioux Lookout Municipality and Sioux Lookout Zone (27 First Nation communities). The report provides screening data for breast, cervical and colorectal cancers
Choosing Wisely Canada

This organization offers practice recommendations for a variety of topics relevant to both primary care and specialists. Although they do not provide practice-level data, the Choosing Wisely Canada recommendations can help you identify improvement goals. For example, if one or more recommendation(s) resonate with you, you can look at your data to find out how you are doing in relation to the recommendation. If you identify a gap between your practice and the recommendation, you could develop an improvement goal to address this gap.

Visit Choosing Wisely Canada to view their recommendations by topic and/or specialty (specialty recommendations are also available in PDF).

Choosing Wisely Canada topics include:

For example, for benzodiazepines, Choosing Wisely Canada provides a deprescribing toolkit. You could set an improvement goal to identify patients currently receiving benzodiazepines that are no longer indicated and set a realistic goal for deprescribing within a set period of time.   

Physician wellness and self-care goals

Physician burnout is a problem affecting an increasing number of physicians. The COVID-19 pandemic, combined with other system-level factors, has resulted in strain impacting physician health and well-being.

Although the OMA recognizes that system-level factors requiring organizational and systemic solutions are the main drivers of burnout, physicians can prioritize their health and wellness within the current system by creating a QI goal around physician wellness. Physician wellness QI goals are meant to support you and will be unique to you and your practice.

Physicians interested in developing an improvement goal around physician health can access the OMA’s burnout toolkit, which includes wellness resources. For example, one of these is the Maslach Burnout Inventory, which can help physicians assess their baseline/current state, develop interventions and measure outcomes/future state; this fee-for-access tool ($15) to assess burnout generates an individual report which can be uploaded to your Practice Improvement Plan.

Observations about your own practice

You can use observations from your own practice to inform your physician wellness QI goals.

For example:

  • How many of your appointments run overtime?
  • How many days of the week do you take lunch?
  • What are some areas in your practice where you can experience greater satisfaction?
  • What are some areas in your practice that would benefit from greater efficiency (e.g. streamlining, bulk work, etc.)?

Learn more about topic-specific improvement ideas.  

Once you have decided on what you would like to improve, decide how you will work towards your goal. Your changes don’t have to be big.

Helpful strategies for change include:

Once you have decided on what you will change, you can set a plan to measure the impact. How will you know if a change is an improvement?

Ask yourself how you will demonstrate success. What is the evidence that your goal was achieved? What data indicates that your goal was achieved?

Your QI goals do not have to be achieved by the time you submit your Practice Improvement Plan to the CPSO; however, you should save your data because you will likely need to refer to it during your next five-year QI cycle with the CPSO.

When you have finished drafting your Practice Improvement Plan, you can submit it to the CPSO through the member portal. Once your selected completion date has passed, a CPSO QI coach will review your Practice Improvement Plan and provide written feedback.

If any of your goals need clarification or could be enhanced, a CPSO QI coach will get in touch with you and may offer one-on-one coaching.