Policies: Peer and Practice Assessment
PPA 4-10: Preamble
Legislative Authority: Health Professions Procedural Code, Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment, and the Dietetics Act, 1991.
Peer and Practice Assessment Overview
The Peer and Practice Assessment (PPA) is an assessment for learning opportunity designed to assess registrants ‘ knowledge, skill and judgement based on the Integrated Competencies for Dietetic Education and Practice (ICDEP) and other College Standards.
Notification
Registrants who are required to undergo a PPA are entitled to at least 14 days’ notice of the start of the assessment. Registrants required to participate (directed and selected) will be notified in February of their requirement to complete a PPA in that year.
Compliance
The College’s PPA is mandatory for all registrants, whether selected or directed. If a registrant does not fully participate in the PPA or cooperate with an assessor or the QA Committee, the QA Committee may refer them to the Inquiries, Complaints and Reports Committee (ICRC).
Format
The Peer and Practice Assessment consists of a Pre-Assessment Survey, Chart Review/ Stimulated Recall and Behaviour Based Interview.
As part of the Peer and Practice Assessment, a range of virtual and/or in-person methods may be used to better understand and support the registrant’s professional practice. These may include, but are not limited to:
- Opportunities for the registrant to discuss their practice through oral or written responses;
- Engaging with practice-based scenarios or case studies to demonstrate professional reasoning and decision-making;
- Reviewing relevant documentation such as client records, self-assessments, and professional development plans;
- Gathering input through conversations or surveys involving the registrant and, where appropriate, their employer, colleagues, or clients.
These approaches are designed to be reflective, informative, and supportive of continuous learning and quality improvement.
PPA 4-20: Selection and Eligibility
Legislative Authority: Health Professions Procedural Code, Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment
Policy Statement
Each year, the College of Dietitians of Ontario (the College) selects registrants to participate in the Peer and Practice Assessment (PPA) as part of its Quality Assurance (QA) Program. The PPA is a supportive, educational process that fosters reflection, promotes competence, and strengthens public trust.
Selection may occur through:
- Random selection using a stratified sampling approach to ensure fairness and proportionality, or
- Referral by the Quality Assurance Committee (QAC) based on defined risk indicators or non-compliance with QA requirements.
The College is committed to ensuring that the selection process is transparent, consistent, and grounded in the principles of right-touch regulation.
- Scope
This policy applies to all general registrants of the College, subject to eligibility requirements and deferral provisions as outlined.
- Procedures
3.1 Random Selection of Registrants
3.1.1 Annual Selection
Each February, the College randomly selects a group of eligible registrants to participate in the PPA. Selection is guided by a proportional stratified sampling technique, which:
- Uses data collected during annual renewal (e.g., number of employers, practice settings, recent practice changes).
- Calculates a cumulative practice indicator score to stratify registrants.
- Randomly selects a proportional number of registrants from each stratum.
3.1.2 Exclusion Criteria:
The following registrants will be excluded from the PPA-selected list:
- Registrants currently not practising in Ontario (either virtually or in-person).
- Registrants on leave.
- Registrants whose certificates of registration are suspended.
- Registrants with temporary memberships.
- Registrants who became General Registrants within the 12 months preceding the selection date.
- Registrants who completed the College’s PPA within the previous five years.
- Registrants are entitled to automatic deferrals (see Section 3 below).
- Registrants with a Quality Assurance Voluntary Undertaking (VUT).
3.2 Referred Registrants
1.1 A registrant may also be referred for a PPA by the QA Committee under the following conditions:
1.1.1 The QAC determines that the registrant has not complied with submitting the SDL Tool or the JKAT. This applies to all general registrants, regardless of their date of joining the College, last PPA date or place of residence.
1.1.2 The QAC concludes that a reassessment is warranted based on findings from a previous PPA and whether any other action has been taken.
1.1.3 The QAC specifies criteria for selection that are posted on the College’s website at least three months before the selection is made1.
3.3 Automatic deferrals
Registrants who hold the following positions will be automatically deferred from the PPA for one year after their term ends, their last day as a College Assessor, or their last day working at the College. This provision helps mitigate any actual or perceived bias or advantage from their involvement:
- CDO QA Committee members
- CDO Professional Practice Staff
- CDO PPA Assessors
If these registrants are selected for reasons other than random selection, they will be required to complete the PPA. In such a case, the QAC may modify the PPA to ensure fairness and avoid any potential bias or conflict of interest. The QAC may also consider whether to modify or suspend the registrant’s participation in the PPA as a committee member, assessor or staff due to the reasons for referral.
3.4 Resignation after selection and notification
If a registrant resigns from the College after being selected for the College’s PPA before the assessment date, they will not be required to complete the assessment. However, if they reapply for registration, they will be required to complete the PPA during the next cycle after reinstatement.
- Commitment to Fairness and Quality
This policy reflects the College’s commitment to fair and proportionate regulation. By incorporating objective selection methods and offering clear guidance on deferrals and referrals, the PPA ensures that assessments are relevant, equitable, and rooted in professional development, not punishment.
[1] Schedule 2: Health Professions procedural code, Quality assurance and other information 80- 83.1 (1)
PPA 4-25: 2-Step PPA Procedure
Legislative Authority: Health Professions Procedural Code, being Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment
- Purpose
To outline the policy and procedure for the Peer and Practice Assessment (PPA) as part of the College’s Quality Assurance (QA) Program. The PPA supports registrants in maintaining competence and enhancing professional practice through reflection, feedback, and learning.
- Policy Statement
The College’s QA program promotes continuous professional development and supports safe, competent, and ethical dietetic practice. The Peer and Practice Assessment (PPA), delivered through a Behaviour-Based Interview (BBI), is an educational and supportive component of this program.
The BBI is grounded in the Integrated Competencies for Dietetic Education and Practice (ICDEP) and was developed in collaboration with practicing dietitians. It enables registrants to reflect on their practice and receive feedback that supports meaningful growth and improvement.
- Scope
This policy applies to all registrants selected by the Quality Assurance Committee to undergo a PPA, whether through routine selection, referral, or other criteria following regulatory requirements.
- Procedure
4.1 Communication
- Registrants will be notified via their online CDO dashboard and email at each stage of the PPA process.
- A handbook with instructions, timelines, and relevant resources will be made available to support registrants’ preparation.
4.2 Assessment Components
The PPA consists of the following components:
a. Pre-Assessment Questionnaire
Identifies key areas of the registrant’s current practice for targeted assessment.
b. Behaviour-Based Interview (BBI)
Conducted virtually with a peer assessor. The interview explores your practice and decision-making process aligned with the ICDEP to assess competencies in a real-world context.
c. Chart Review (for dietitians providing direct client care)
Registrants reflect on five selected client records and complete the Reflective Record-Keeping Questionnaire. This supports professional insight into documentation quality and care delivery.
4.3 Chart Review Process (if applicable)
- Registrants select five client health records (current or recently discharged).
- Records must be de-identified to protect client privacy.
- Registrants complete the Reflective Record-Keeping Questionnaire based on the selected records.
- During the BBI, the assessor will ask questions about these cases. If key questions are sufficiently addressed for at least three records, discussion of additional records may not be required.
4.4. Feedback Report
- A written summary prepared by the assessor outlines strengths, developmental areas, and suggestions to support ongoing learning.
PPA 4-30: Requests for Extension and Deferrals
Legislative Authority: Health Professions Procedural Code, being Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment.
POLICY STATEMENT
Registrants of the College may request an extension or deferral for the Peer and Practice Assessment (PPA) if extenuating circumstances arise.
Extension: Additional time granted to extend the PPA beyond the completion date.
Deferral: Providing a rescheduling of the start date to complete the PPA in a given year.
PROCEDURE
1. Filing of a Request for an Extension or Deferral
1.1 Submission: A request to extend or defer the PPA should be made in the electronic format made available by the College. If a registrant is unable to submit the request themselves, another individual may submit it on their behalf. Requests must be received by the deadline indicated on the form unless otherwise permitted by the College. If additional time is needed to file the request, the registrant must provide a reason for the delay.
1.2 Accessibility: The College will make reasonable accommodations to ensure that registrants can submit requests without barriers, in line with Equity, Diversity, Inclusion, and Belonging (EDIB) and Accessibility for Ontarians with Disabilities Act, 2005, S.O. 2005, c. 11 (AODA) principles.
2. Details of the Request for an Extension or Deferral:
2.1 Required Information: The written request should include the following:
- The registrant’s name and registration number
- Whether the request is for an extension or deferral
- Current work status
- Any pertinent information or reasons supporting the request (e.g. duration of the extension or deferral requested). Registrants may be asked to provide supporting documentation, if available.
2.2 Review Process: If insufficient information is provided to make the decision, the College will notify the registrant and provide the registrant an opportunity to submit additional details.
3. Decisions Regarding a Request for Extension or Deferral
3.1 The QA Staff will review all requests for extensions and deferrals on behalf of the Committee. The registrant will be notified by email, generally within five business days of receipt of their request.
3.2 QA Staff will grant extensions and deferrals based on consideration of extenuating circumstances, including but not limited to:
3.2.1 Current hospitalization
3.2.2 Major illness or self/family crisis
3.2.3 Bereavement
3.2.4 Personal hardship
3.2.5 Current leave of absence, including parental leave
3.3 Request to defer the PPA for registrants who are referred to participate in the PPA will be reviewed by the Committee on a case-by-case basis, with careful consideration of the individual’s circumstances and any risk to the public.
4. Other Requests: Requests based on reasons other than those mentioned in Section 3 above will be referred to the Committee. Each request will be assessed individually, with decisions made on a case-by-case basis.
5. Notification of Decision: The registrant will be informed of the decision by email, generally within five business days of the decision.
6. Additional Requests for Extensions: If an extension is granted and additional time is requested, the registrant may submit an additional written request. Each additional request will be reviewed with the same attention to fairness, proportionality, and individual circumstances as the initial request.
PPA 4-40: Registrant’s Submission Regarding an Assessor Report
Legislative Authority: Health Professions Procedural Code, being Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment.
POLICY STATEMENT
Upon receiving the Assessor’s report, the registrant has the right to submit any additional information or context they believe is relevant for the Quality Assurance (QA) Committee to consider before making a final decision on the PPA. The QA Committee is committed to a risk-based and non-punitive approach. All submissions will be reviewed thoughtfully, considering both the registrant’s input and the Assessor’s report.
PROCEDURE
1. Filing a Submission that may be relevant to consider
1.1 Registrants who wish the Committee to consider other facts or information about the Assessor’s Report should submit this information through their dashboard. This will be communicated to registrants when the report is submitted to them.
1.2 Submissions should be received within 14 days of the notification of the Assessor’s report. Upon submission, registrants will receive an automatic confirmation that their submission has been received by the College.
1.3 The College will provide information to registrants to ensure the submission process is accessible.
2. Decision Regarding a Registrant’s Submission
2.1 The QA Committee, or a panel thereof, will review the registrant’s submission alongside the Assessor’s report.
2.2 Based on the review, the Committee may:
2.2.1 Accept the Assessor’s report and continue with the PPA process
2.2.2 Request the registrant to undergo a second BBI with the same or a different Assessor
2.2.3 Implement any other remedy within the Committee’s statutory authority that aligns with the risk assessment framework.
2.2.4 Delay the decision if additional information is needed to make a fair and informed determination.
3. The Committee may require the registrant to pay for the cost of a new PPA depending on the circumstances.
PPA 4-50: Reconsideration of a Quality Assurance Committee Decision Regarding an Assessor’s Report
Legislative Authority: Health Professions Procedural Code, being Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL, s 29(1)-(14) Peer and Practice Assessment.
POLICY STATEMENT
Registrants have the right to request that the Quality Assurance (QA) Committee reconsider its decision regarding an Assessor’s report for their Peer and Practice Assessment. The Committee is committed to reviewing all reconsideration requests with a fair, risk-based, and non-punitive approach.
PROCEDURE
1. Filing of a request for Reconsideration
1.1 Any registrant of the College who wishes the Committee to reconsider their decision of a Peer and Practice Assessment decision may make a request.
1.2 The College should receive the request 30 days from the letter of notification of the Committee’s decision. The request should be made by email.
1.3 An acknowledgement of receipt of the request will be emailed typically within five business days.
2. Details of the request
2.1 Required Information: The written request should include the following:
i) The registrant’s name and registration number
ii) A clear reason for requesting reconsideration of the Committee’s decision.
iii) Any information that may be pertinent and supportive of the reason for the request.
3. Decision Regarding a ‘Request to Reconsider a Decision’:
3.1 Request to reconsider a decision will be reviewed by the Committee on an individual case basis. This will include reviewing information sent in by the registrant, the Committee decision and the assessor’s report/s on the Peer and Practice Assessment.
3.2 The Committee may choose between the options listed below:
3.2.1 Do nothing and continue with the peer & practice assessment and enhancement process as per the QA Regulation and policies;
3.2.2 Require the registrant to undergo a new peer and practice assessment with the same or a different assessor;
3.2.3 Implement any other remedy within the Committee’s statutory authority.
3.3 The Committee’s decision regarding the request for reconsideration will usually be communicated within five business days of the Committee’s decision.
3.4 The Committee may require the registrant to pay for a new peer or practice assessment depending on the circumstances.
3.5 A decision may be delayed if the Committee requires additional information to make a decision.
PPA 4-60: Accommodation of Special Needs
Legislative Reference: Human Rights Code; Policy on ableism and discrimination based on disability; Policy and guidelines on disability and the duty to accommodate and the Accessibility for Ontarians with Disabilities Act, 2005, S.O. 2005, c. 11
POLICY STATEMENT
The College of Dietitians of Ontario is committed to providing equitable access to the Peer and Practice Assessment (PPA) process for all registrants, including those with disabilities as defined under the Human Rights Code. Registrants who require accommodation due to a disability will be supported through a process that upholds their dignity, individuality, privacy, and autonomy. The College of Dietitians of Ontario will work collaboratively with registrants to ensure that the necessary accommodations are provided in a manner by ensuring that ensures self-worth, individuality, privacy, confidentiality, comfort and autonomy are maintained.
PROCEDURE
- Submission of Accommodation Requests
1.1 Deadline for Requests: Accommodation requests should be submitted in writing or another recorded format and received by the College at least 30 business days before the scheduled assessment date. If the assessment has not been set, the request should be made as early as possible. Requests submitted, less than 30 business days before a scheduled assessment, will be reviewed but may result in a delay in the assessment to ensure that appropriate accommodation is made.
1.2 Content of the Request The request should include:
- documentation detailing the nature of the accommodation as it relates to the assessment
- a description of the specific accommodation required.
- Review and Implementation of Accommodations
2.1 Collaborative Process: The College will engage the registrant in a collaborative process to identify and implement the necessary accommodations. This process will respect the registrant’s privacy and ensure that their individuality is maintained.
2.2 Ensuring Fair Opportunity: Accommodations will provide the registrant with a fair opportunity to demonstrate their competence during the PPA, ensuring that the process is inclusive and non-punitive.
2.3 Timeliness of Measures: Both Temporary and permanent accommodation may be provided, depending on the nature of the request. The goal is to facilitate the registrant’s participation in a timely and effective manner.
- Costs and Resources
3.1 Cost Coverage: The College will cover any costs associated with providing the required accommodation.
PPA 4-70: Assessors
Legislative Reference: Health Professions Procedural Code, Schedule 2 to The Regulated Health Professions Act, 1991, s 80.1 and O. Reg. 593/94: GENERAL; Regulated Health Professions Act, 1991 Section 82(1)
POLICY STATEMENT
The Quality Assurance (QA) Committee appoints qualified Registered Dietitians to conduct Peer and Practice Assessments (PPA) in a fair, confidential, secure and consistent with the principles of Equity, Diversity, Inclusion, and Belonging (EDIB). Assessors conduct Assessments and prepare reports for the QA Committee following established procedures approved by the College.
PROCEDURE
1. Assessors
1.1 The Director of Professional Practice and Quality Assurance staff will recruit Assessors for the Peer and Practice Assessment based on core competencies and attributes. This process is critical in ensuring Assessors have a clear understanding of CDO’s public protection mandate, can effectively participate in CDO work, can assess and evaluate information and can work collaboratively with colleagues and staff.
1.2 Staff will submit the names of qualified Registered Dietitians (RDs) to the QA Committee for appointments as a College Assessor.
- Compensation for Assessors
2.1 The Registrar and Executive Director will set the rates for compensation for Assessors based on market value and will be transparently shared during the recruitment process.
- Assessor Contracts
3.1 Assessors will sign a contract with the College outlining the expectations1, including:
- Number of assessments to be conducted over a specified period.
- Roles and responsibilities.
- Compensation.
- Confidentiality requirements.
- Conflict of interest declarations.
- Term of the contract.
- Training of Assessors
4.1 Assessors will be provided with appropriate training by the College.
- Assignment of Assessors
5.1 The QA Committee will appoint an assessor for each assessment, using transparent criteria. This may involve assigning the next available Assessor from a roster, matched to the registrant being assessed based on, e.g. conflict of interest screening, availability and scheduling or matching assessors and registrars with similar practice context, e.g. population Health or Nutrition Care.
5.2 Equity in Assignment:
The assignment process will ensure that Assessors are matched in a manner that is free from bias and aligned with the right-touch, risk-based, and non-punitive principles of the QA program.
1 See Contract for Assessors.