Policies: Peer and Practice Assessment

The Peer and Practice Assessment is a learning opportunity designed to assess registrants’ knowledge, skill and judgement based on the Integrated Competencies for Dietetic Education and Practice (ICDEP) and other College’s Standards.

The Purpose of the Colleges’ Practice Assessment is:

• To meet statutory obligations under the Regulated Health Professions Act (RHPA), 1991
• To assure the public and system partners that Registered Dietitians (RDs) practice safely, competently and ethically.
• To provide positive reinforcement to RDs who provide safe, ethical and competent nutrition services.
• To assist RDs in improving their competence in a positive and supportive environment using flexible and acceptable processes for registrants.

Notification

Registrants who are required to undergo a peer and practice assessment are entitled to at least 14 days’ notice of the start of the assessment. Registrants required to participate (directed and randomly selected) for the Practice Assessment (PPA) 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 randomly or otherwise. If a registrant does not fully participate in the PPA or cooperate with an assessor or the QA Committee, the Committee may refer the matter to the Inquiries, Complaints and Reports Committee (ICRC).

Format

The Peer and Practice Assessment consists of 2 components: Step1: Pre-Assessment Survey, Step 2: Chart Review/ Stimulated Recall and Behaviour Based Interview.

The Peer and Practice assessment may also include, but is not limited to, one or more of the following virtual and/or in-person assessment methods:

• requiring the registrant to answer, orally or in writing, questions that relate to the registrant’s practice;
• requiring the registrant to solve simulated problems or case studies that relate to the practice of dietetics;
• reviewing client records and the registrant’s self-assessment and professional development records; and
• interviewing or surveying the registrant and their employer, employees, colleagues, peers and, clients.

Policy Statement

Each year the College shall randomly select the names of eligible registrants required to undergo the College’s 2 Step Peer and Practice Assessment (PPA). The College uses a computer program to randomly choose registrants to participate in the PPA process. In addition, a registrant is required to undergo the College’s PPA for other reasons (e.g., non-compliance with other QA requirements such as the Self-Directed Learning (SDL) tool or Jurisprudence and Assessment Knowledge Tool (JKAT) or as directed by the Quality Assurance Committee (QAC).

Procedure

1. Registrants Eligible for Random Selection

1. The College will randomly select 10% of its registrants in February of every year.
2. The criteria for the composition of the random pool shall exclude:
   1. Registrants not practicing in Ontario;
   2. Registrants on leave
   3. Those whose certificates of registration are under suspension;
   4. Those with temporary registrations;
   5. Registrants who became General Registrants less those 12 months prior to the random selection date
   6. Registrants who completed the College’s Peer and Practice Assessment within the previous five years.
   7. Those entitled to automatic deferrals (as per #3 below):
      • CDO QA Committee members
      • CDO Professional Practice Staff
      • CDO PPA Assessors

2. Referred Registrants

A registrant may be required to undergo the Peer and Practice Assessment (PPA):

• If the Committee finds that they have not complied with the submission of the Self-Directed Learning Tool and/or the Jurisprudence Knowledge and Assessment Tool.  This includes all general registrants regardless of the date of joining CDO, year of last PPA or place of residence.
• Whether or not any other action has been taken as a result of a report from a Peer and Practice Assessment and the Committee concludes that a re-assessment is warranted.
• Based on criteria specified by the Committee and posted on the College’s website at least three months before a registrant is selected based on those criteria. 

3. Automatic Deferrals

If a registrant, who is in one of the positions listed below, is randomly selected from a pool of registrants, they will be deferred from the Practice Assessment for a period of one year following the last date of their term; the last date they acted as a College Assessor; or the last date they worked at the College. In addition, automatic deferrals are granted to these registrants to reduce or eliminate any advantage to the registrant or appearance of bias that might accrue from their involvement.

• CDO QA Committee members
• CDO Professional Practice Staff
• CDO PPA Assessors

If any of the above registrants are eligible due to grounds other than random selection, they will be required to complete the Practice Assessment.

In such a case, the QA Committee may consider modifying the Practice Assessment to reduce or eliminate any advantage to the registrant or bias that might accrue from their involvement. In addition, the Committee may consider whether steps should be taken to modify or even suspend the participation of the registrant as a Committee member, Assessor or Staff as a result of the reasons for referral.

Resignation after Random Selection

A registrant who resigns from the College after they have been selected for the College’s Peer and Practice Assessment, but before the date of the scheduled Peer and Practice Assessment, will not be required to complete the peer and practice assessment.  If the registrant reapplies for registration, upon reinstatement, the registration will be required to complete the Peer and Practice Assessment at the next cycle.

Policy Statement

Each year the College shall randomly select the names of eligible registrants required to undergo the College’s Peer and Practice Assessment. A registrant may be required to undergo the College’s Peer and Practice Assessment for other reasons as well (e.g., non- compliance with other QA requirements such as the Self-Directed Learning (SDL) tool or JKAT or as directed by the Quality Assurance Committee (QAC).

Procedure

1. 10% of eligible registrants are selected to participate in Step 1 of the PPA-Multisource Feedback Surveys. The 2 Step PPA process is attached as appendix A.
    
2. Each registrant is required within 90 days of notification to complete and submit electronically:
   • Self-Assessment survey
   • Minimum 6 Colleague Surveys*
   • Minimum 9 Patient Surveys (if applicable)**
3. Once the survey results are compiled, registrants whose multisource feedback scores fall outside the reference criteria and a random selection (3%) of registrants who score at or above the reference criteria set by the QA Committee move to Step 2-the Behaviour-based Interview and chart review/stimulated recall.
    
4. To continue to focus on strategies for mitigating the risk of harm in dietetic practice, a stratified random selection (6%) from the selected registrants’ cohort to move directly to Step 2-the Behaviour-Based Interview and chart review/stimulated recall. Stratified random sampling divides a membership population into subgroups. The criteria for the composition of the groups or strata shall include the following identified risk-based factors:
   • Practice Setting – Solo Practice (A community-based professional practice/business composed of a single practitioner who delivers health services).
   • Area of Practice: (Clinical Practice; Community; Food and Nutrition Management)
5. The QA Staff sends each registrant their Step 1 feedback results and the next steps (if any) in the 2 Step PPA. Anyone who is not required to move onto Step 2 is considered to have completed the PPA and is removed from random selection for the next five years.
    
6. Registrants moving onto Step 2 will be notified online of each step of the process. The specific procedure is summarised in appendix B.

**If their work setting makes it difficult to approach patients/families (e.g. ICU), to complete surveys. They may have an option to move directly to Step 2 by contacting the QA Manager to discuss this option.

*If at least 6 Patient Surveys and at least 4 Colleague Surveys have been received and feedback is positive, these constitute completion of Step 1 PPA.

Policy Statement

Registrants of the College may formally request an extension or deferral for the Peer and Practice Assessment (PPA) if extenuating circumstances exist.

The Quality Assurance (QA) staff and Committee wil consider the registrant’s circumstances when granting or refusing a request. No request is denied without first being considered individually by the Committee.

Extension: Providing additional time to complete PPA Step Two beyond the due date. Extensions are not given for Step 1.

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

A request to extend Step 2 or defer the PPA should be made by email (on the form provided by the College). Someone else may request on behalf of the registrant if they cannot make the request themselves. Unless otherwise permitted by the College, request for extension or deferral must be received by the deadline indicated on the form. If a registrant requires more time to file their request, they must give their reason for the delay.

2. Details of the Request

The written request may include the following:

1. The registrant’s name and registration number;
2. Whether the request is for an extension or deferral;
3. An indication of current work status;
4. Any information/reasons that is pertinent and supportive of the request (e.g. amount of time being requested, doctor’s note); and

The decision may be delayed, or the request for extension or deferral denied if there is insufficient information to make the decision.  In this situation, the registrant will be notified and may choose to provide further information.

3. Decisions Regarding a Request for Extension or Deferral

3.1 All requests for extensions and deferrals will be reviewed by the QA Staff on behalf of the Committee. The registrant will be notified by email, generally within five business days, of receipt of their request. 

3.2 The QA Staff will grant extensions and deferrals on behalf of the Committee based upon consideration of extenuating circumstances for registrants who were randomly selected, such as the following:

• Current hospitalization
• Major illness or self/family crisis
• Bereavement
• Personal hardship
• Current leaves of absences, including parental leave

3.3 Request to defer the PPA for registrants who are Referred, Directed or Required will be reviewed by the Committee on a case-by-case basis.

3.4 If a request for an extension or deferral of a specific time frame is made, the Committee and Staff may consider this time frame but will not be limited by it.

4. Request for extension or deferral reasons other than those mentioned in Seciton 3 above will be referred to the Commitee. Decisions will be made by case-by-case basis.

5. The registrant will be notified by email of the decision. This notification will be emailed to the registrant, usually within five business days of the decision.

6. When an extension is granted, if the registrant desires an additional extension, they are required to submit a subsequent written request.

Policy Statement

Upon receipt of an Assessor’s report, registrants shall be informed of their right to make a submission that may be relevant for review and consideration by the Quality Assurance Committee before making a decision. The Committee shall consider the registrant’s request and the Assessor’s report when deciding.

Procedure

1. Filing a Submission that may be relevant to consider

1.1 Any registrant of the College who wishes the Committee to consider other facts or information (a submission) relevant to assessor’s report before a decision is made are welcome to submit to their dashboard. 

1.2 Submission should be received within 14 days from the date of the notification of the Assessor’s report. The registrant will receive an automatic message that the College received their submission. 

2. Decision Regarding a Registrant’s Submission

2.1 The Committee, or a panel thereof, will review both the registrant’s submission and the assessor’s report. 

2.2 Outocome of the review of Submission and Assessor’s Report may result in the following next steps”

1. Accept the assessor’s report and continue with the PPA process
2. Require registrant to undergo a second PPA (Step 2) with the same or different assessor
3. Any other remedy within the authority of the Committee
4. A decision may be delayed if the Committee requires additional information to make a decision.

3. The Committee may require the registrant to pay for the cost of a new PPA depending on the circumstances.

Policy Statement

Registrants shall have the right to request that the Quality Assurance Committee reconsider their decision respecting an Assessor’s report for their Peer and Practice Assessment.  The Committee shall review a registrantsquo;s request to have a decision reconsidered.

Procedure

1. Filing of a request

1.1 Any registrant of the College who wishes the Committee to reconsider their decision of a Peer and Practice Assessment decision is welcome to file 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 usually within five business days.

2. Details of the request

The written request should include the following:

1. The registrant’s name and registration number.
2. Reason for requesting for reconsideration of the Committee’s decision.
3. 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:

1. Do nothing and continue with the peer & practice assessment and enhancement process as per the QA Regulation and policies;
2. Require the registrant to undergo a new peer and practice assessment with the same or a different assessor;
3. Any other remedy within the authority of the Committee.

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.

Policy Statement

A registrant, who has a disability (defined below according to the Human Rights Code) and requires special accommodation for that disability in order to complete the assessment, may request that the College make those provisions. The College of Dietitians will work with the registrant to accommodate their needs ensuring that self-worth, individuality, privacy, confidentiality comfort and autonomy is maintained.

Procedure

1. A request in writing or some other permanent medium should be received at least 30 business days before the date of the assessment or before the assessment date is arranged. Requests received later will be reviewed, but may result in a delaying the practice assessment in order to make any necessary accommodation.
2. The request from the registrant must include documentation of the relevant nature disability and a description of the special accommodation requested.
3. The College will work with the registrant to accommodate their special needs and ensure that the registrant has a fair opportunity to demonstrate competence.
4. Temporary or permanent measures may be necessary to ensure that the registrant can participate in the Peer and Practice Assessment in a timely manner.
5. The College will assume any costs incurred as a result of accommodating a registrant’s special need.