What to Expect from Your First CPSO Peer Assessment Dr. Ian Cowan, - PowerPoint PPT Presentation

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 !