Introduction

Assessment is one of the Fairness Commissioner's mandated roles under the Fair Access to Regulated Professions and Compulsory Trades Act, 2006 (FARPACTA) and the Regulated Health Professions Act, 1991 (RHPA) – collectively known as fair access legislation.

Assessment Cycle

One of the primary ways the OFC holds regulators accountable for continuous improvement is through the assessment of registration practices using a three-year assessment cycle.

Assessment cycles alternate between full assessments and targeted assessments:

• Full assessments address all specific and general duties described in the fair-access legislation.
• Targeted assessments focus on the areas where the OFC made recommendations in the previous full assessment.

Focus of this Assessment and Report

The 2016-2018 assessment of the College of Homeopaths of Ontario (the College) is a full assessment.

The OFC’s detailed report captures the results of the full assessment. The assessment summary provides the following key information from the detailed report:

• duties that were assessed
• an overview of assessment outcomes for specific duty practices
• an overview of comments related to the general duty
• commendable practices
• recommendations

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Assessment Summary

Specific Duties

Specific duties assessed

The regulator has been assessed in all of the specific duties.

Comments

The College of Homeopaths of Ontario (the College) was proclaimed April 1, 2015. As with any new organization, the College is building its organizational competencies and is continuously working to enhance its processes. In this assessment, the OFC found that the College shows a strong commitment towards developing and implementing fair registration practices. In particular, the College has demonstrated all of the practices in the following specific-duty areas:

• Information for Applicants
• Timely Decisions, Responses and Reasons
• Internal Review or Appeal
• Information on Appeal Rights
• Documentation of Qualifications
• Access to Records

The OFC has identified seven areas where the regulator needs to take further actions to meet their specific-duties obligations.

General Duty

Assessment method

The regulator selected the following method for the assessment of the general duty:

a.	OFC practice-based assessment (following the practices in the Assessment Guide)
b.	Regulator practice-based self-assessment (following the practices in the Assessment Guide)
c.	Regulator systems-based self-assessment (in which it explains systemically and holistically how it meets the general duty)

Principles assessed

The regulator has been assessed on all of the general duty principles: transparency, objectivity, impartiality and fairness.

Comments

The College implements practical and logical measures to achieve transparent, objective, impartial and fair registration practices. However, in this assessment the OFC has identified thirteen areas related to all four of the general duty principles where further developments are needed.

Commendable Practices

A commendable practice is a program, activity or strategy that goes beyond the minimum standards set by the OFC assessment guides, considering the regulatory body’s resources and profession-specific context. Commendable practices may or may not have potential for transferability to another regulatory body.

The regulatory body is demonstrating commendable practices in the following areas:

Specific Duty

Information for Applicants

1. Integrating feedback from applicants on the individual assessment (IA) process into audio-visual and registration materials available on the website. Changes made as a result of the feedback ensures that information is user friendly and addresses a wide range of common questions making it easier for applicants to understand how the process operates.

General Duty

Transparency

1. Allowing applicants the opportunity to complete the various steps in the pre-assessment and registration processes in any order and to also complete several of the steps concurrently. This increased flexibility enables applicants to more efficiently complete the various steps required.
2. Providing information sessions on the IA process in collaboration with the third-party assessor to help applicants better understand the competencies being assessed and how to prepare materials for their assessment submissions.

Fairness

1. Pro-rating registration fees for the first year of membership and providing applicants with a need for accommodation option to pay by installment.
2. Approving a competency-based and clinical supervision refresher program for applicants who demonstrated gaps in their education and/or clinical training and are unable to meet registration requirements.

Recommendations

The regulator can improve in the following areas:

Specific Duty

Assessment of Qualifications

1. Develop and implement guidelines for decision-makers to conduct internal appeals of assessment decisions as part of the Substantially Equivalent Competence Assessment (SECA) process. (Practice 6.3)
2. Continue to develop guidelines, policies or other similar documents for those involved in the assessment of qualifications about the potential for bias or risk to impartiality in the assessment process. These documents should include content on:
   • Characteristics or types of bias and/or situations that may compromise the impartiality of assessment decisions;
   • Procedures to follow where there is a potential for bias; and
   • Actions to prevent discriminatory assessment practices. (Practice 6.11)
3. Implement procedures to conduct a risk assessment or ongoing review process to:
   • Identify potential bias in assessment methods or procedures;
   • Develop and record mitigating strategies to address potential risks in guidelines for assessors and decision-makers; and
   • Establish a means to ensure corrective actions are implemented in a timely manner. (Practice 6.12)
4. Develop and implement a formal and structured process to verify that third-parties’ assessment practices are transparent, objective, impartial and fair. The process should include procedures to:
   • Evaluate and monitor third-parties’ assessment practices; and
   • Identify potential issues and, if any issues are identified, take actions to address them. (Practice 6.15)

Training

1. Develop a formal and structured process to identify and deliver training to those individuals involved in assessing qualifications, making registration decisions, making internal review decisions, and identifying and applying specials considerations in the assessment of applicants. (Practice 7.1)
2. Develop and implement training opportunities for staff and committee members involved in assessment and registration decisions that address the following topics:
   • Anti-discrimination;
   • Cultural diversity;
   • Objectives of fair-access law; and
   • Objective and impartial decision-making and what it means in the context of the registration process. (Practice 7.2)
3. Develop guidelines, policies or other similar documents for onboarding and ongoing training of staff and committee members. Include procedures for:
   • Identifying when new and/or incumbent staff and committee members require training;
   • Establishing timelines for the completion of training; and
   • Verifying that training has been completed according to these timelines. (Practice 7.3)

General Duty

Transparency

1. Implement a formal and structured process to seek feedback from applicants and members on their experiences with the SECA and registration processes. Incorporate feedback where appropriate in discussions about registration policy and practices.

Objectivity

1. Develop and implement a work plan to document formal guidelines explaining the decision-making steps and procedures to consistently and accurately apply criteria for the good character and criminal reference check registration requirements.
2. Develop formal procedures to inform decision-makers of any changes to registration criteria, policies and procedures to ensure that they are given information that is current and relevant in a timely manner.
3. Implement measures to safeguard and promote consistency in registration decisions. For example, continue to develop and refine guidelines and tools that require decision-makers to follow the same step sequence in applying registration requirement criteria, policies and procedures to all applicants.
4. Develop and implement measures to monitor, verify and improve the consistency and accuracy of registration decisions. Measures may include a periodic review of registration decision trends by a designated staff member or a standing agenda item for the registration committee to discuss past decisions.

Impartiality

1. In documents, such as policies, guidelines and codes of conduct, for staff and committee members involved in registration and internal reviews processes:
   • Document characteristics and sources of bias and/or situation that may compromise the impartiality of registration decisions;
   • Provide strategies to manage situations of bias; and
   • Outline conduct to follow for decision-making that is impartial and free of discrimination.
2. Develop guidelines for making registration policy decisions that include steps to identify and address any internal and/or external factors that may improperly influence decisions.
3. Implement control procedures to avoid or minimize bias, to monitor and identify potential sources of bias, and to take corrective actions as needed for impartial decision-making.
4. Develop a code of conduct that commits decision-makers to bias- and discrimination-free registration practices.

Fairness

1. Develop and implement procedures for a scheduled review of registration requirements to verify that these requirements remain relevant and necessary to practice in the profession.
2. Develop an internal audit process that will:
   • Identify registration decisions that are in compliance and non-compliance with established registration criteria, policies and procedures;
   • Identify the potential causes of non-compliance; and
   • Provide guidelines for implementing corrective actions, as needed.
3. Develop and implement monitoring processes to ensure that decision-makers adhere to established timelines for:
   • Making and communicating decisions and reasons to applicants;
   • Responding to applicants’ inquiries or requests;
   • Providing applicants with access to internal reviews of assessment decisions; and
   • Making and communicating decisions about internal reviews.
4. Develop a set of procedures to consider requests for special accommodation from applicants undergoing the pre-assessment and registration processes and possible actions the College may take to accommodate requests. Include reference to these documented procedures in information for applicants and registration materials.

Assessment History

The College was proclaimed at the time when the OFC had already initiated the previous assessment cycle. This is the first assessment of the registration practices for the College.

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Detailed Report^[1]

Specific Duty

1. Specific Duty — Information for Applicants

RHPA, Schedule 2, s. 22.3

1. The regulator describes requirements for registration on its website. [Transparency]

Assessment Outcome

Demonstrated

OFC Comments

The College’s website provides applicants and other interested stakeholders with a range of registration guides, flowcharts, frequently asked questions and factsheets that describe how registration requirements may be satisfied and alternative ways of meeting the requirements, where applicable. Specific online resources include a handbook for applicants that are required to undergo the Substantially Equivalent Competence Assessment (SECA) process to determine their eligibility to register with the College and an audio-visual learning tool for the individual assessment (IA) requirement.

Commendable Practice

Integrating feedback from applicants on the individual assessment (IA) process into audio-visual and registration materials available on the website. Changes made as a result of the feedback ensures that information is user friendly and addresses a wide range of common questions making it easier for applicants to understand how the process operates.

2. The regulator describes all the steps in the registration process on its website, including any processes for assessing qualifications. [Transparency]

Assessment Outcome

Demonstrated

3. The regulator provides information on its website about how long the registration process usually takes, including the time required for assessing qualifications. [Transparency]

Assessment Outcome

Demonstrated

4. The regulator publishes a fee scale on its website, showing all registration fees that are under the regulator's control, including the fees required for assessing qualifications. [Transparency]

Assessment Outcome

Demonstrated

5. The regulator ensures that the information required by practices 1-4 in this section is clear, accurate, complete and easy to find. [Transparency]

Assessment Outcome

Demonstrated

2. Specific Duty — Timely Decisions, Responses and Reasons

RHPA, Schedule 2, s.20 (1)

1. If a regulator rejects an application, it gives written reasons to the applicant. [Fairness, Transparency]

Assessment Outcome

Demonstrated

3. Specific Duty — Internal Review or Appeal

RHPA, Schedule 2, s. 15, s. 17, s. 19, s. 22.3

1. The regulator provides applicants with an internal review of, or appeal from, registration decisions. [Fairness]

Assessment Outcome

Demonstrated

2. The regulator implements rules and procedures that prevent anyone who acted as a decision-maker in a registration decision from acting as a decision-maker in an internal review or appeal of that same registration decision. [Impartiality]

Assessment Outcome

Demonstrated

3. The regulator provides information on its website that informs applicants about opportunities for an internal review or appeal. [Transparency]

Assessment Outcome

Demonstrated

4. Specific Duty — Information on Appeal Rights

RHPA, Schedule 2, s. 20, s. 21, s. 22

1. On its website, the regulator informs applicants of their right to request further review of, or appeal from, the review or appeal decision. [Transparency]

Assessment Outcome

Demonstrated

5. Specific Duty — Documentation of Qualifications

RHPA, Schedule 2, s. 22.4(1)

1. The regulator provides information on its website about the documents that must accompany an application to demonstrate qualifications. [Transparency]

Assessment Outcome

Demonstrated

6. Specific Duty — Assessment of Qualifications

RHPA, Schedule 2, s. 22.4(2)

1. On its website, the regulator informs applicants about the process, criteria, and policies for the assessment of qualifications. [Transparency]

Assessment Outcome

Demonstrated

2. The regulator communicates the results of qualifications assessment to each applicant in writing. [Transparency]

Assessment Outcome

Demonstrated

OFC Comments

The College communicates assessment results to applicants undergoing the SECA process in writing via mail and email. Communications include information on the criteria that the applicant did or did not meet, what an applicant can do to close any gaps identified, and their next steps in the registration process. For applicants that are ineligible to register for membership, the communications also include information on the available options for internal and external reviews of the assessment decision.

The OFC understands that the College is currently in the process of documenting guidelines for communicating assessment results in writing to applicants undergoing the SECA process. In addition, the College stated that they plan to further refine the templates used to communicate assessment results to ensure that they are clear, consistent and complete. The OFC supports these efforts.

Suggestions for continuous improvement

Continue to develop guidelines for internal reviewers and committee members that include procedures for developing written decisions and reasons letters that communicate assessment results to applicants undergoing the SECA process.

3. The regulator gives its assessors access to assessment criteria, policies and procedures. [Transparency]

Assessment Outcome

Partially Demonstrated

OFC Comments

The College provides its internal reviewers and committee members with access to assessment criteria and policies to make assessment decisions as part of the SECA process. The College informed the OFC that they also take measures to promptly notify internal reviewers and committee members about changes to these criteria and policies through meetings, training sessions and consultations with the Registrar.

When assessing this practice, the OFC was also looking for evidence that the College has documented procedures for internal reviewers and committee members to use in interpreting and applying assessment criteria and policies in their decisions. The OFC understands that the College is presently finalizing documented procedures related to the SECA process for internal reviewers and committee members. The OFC supports this effort.

The OFC noted that the College does not have documented procedures for decision-makers to consider requests for internal reviews of assessment decisions. The College explained that procedures outlined for decision-makers in the Individual Assessment Review and Appeals Process Policy would be applied in these cases. The OFC recommends, however, that the College develop specific guidelines for decision-makers dealing with internal reviews of SECA decisions for consistency, accuracy and transparency for applicants.

Recommendations

Develop and implement guidelines for decision-makers to conduct internal appeals of assessment decisions as part of the SECA process.

Suggestions for continuous improvement

Continue to document assessment criteria, policies and procedures related to the SECA process for internal reviewers and committee members. As documentation proceeds, promptly inform those involved in the process of all resulting changes.

4. The regulator shows that its tests and exams measure what they intend to measure*. [Objectivity]

Assessment Outcome

Not Applicable

OFC Comments

This practice does not apply to the College as they do not conduct examinations.

5. The regulator states its assessment criteria in ways that enable assessors to interpret them consistently. [Objectivity]

Assessment Outcome

Demonstrated

6. The regulator ensures that the information about educational programs that is used to develop or update assessment criteria is kept current and accurate. [Objectivity]

Assessment Outcome

Not Applicable

OFC Comments

The College does not use information about educational programs to develop or update assessment criteria as part of the SECA process.

7. The regulator links its assessment methods to the requirements/standards for entry to the profession or trade. [Objectivity]

Assessment Outcome

Demonstrated

8. The regulator requires that assessors consistently apply qualifications assessment criteria, policies and procedures to all applicants. [Objectivity]

Assessment Outcome

Demonstrated

OFC Comments

The College informed the OFC that internal reviewers may take previous assessment decisions into consideration when assessing a file if the education and clinical training content is the same or substantially similar to that undertaken by the applicant seeking registration. As per the College’s interpretation, the same or substantially similar means the same year or same time period without changes to the content of the educational program. The OFC understands that guidelines for this practice are not documented at the present time. It might be helpful for the College to develop guidelines to direct internal reviewers to refer to previous assessment decisions only when appropriate and to ensure that such decisions are based on information that is current and accurate.

Suggestions for continuous improvement

Develop guidelines that instruct internal reviewers to make or verify assessment decisions by referring to precedent cases only when the educational program completed by the present applicant was in the same year.

9. The regulator uses only qualified assessors to conduct the assessments. [Objectivity]

Assessment Outcome

Demonstrated

10. The regulator monitors the consistency and accuracy of decisions, and takes corrective actions as necessary, to safeguard the objectivity of its assessment decisions. [Objectivity]

Assessment Outcome

Demonstrated

OFC Comments

The College has reported that they take various measures to monitor and verify the objectivity of assessment decisions, including consulting with legal counsel on particular files and providing additional training to internal reviewers and third-party assessors to ensure that assessment procedures deliver consistent results. The College additionally reviews and responds to trends in assessment outcomes, in requests for appeals and overturned decisions, and in applicant complaints on the IA process. Improvements have been made as a result of these analyses to the assessment process, communications to applicants, and engagement between the third-party assessment provider and registration staff.

The College informed the OFC that they are also in the process of developing a long-term strategy to monitor the consistency and accuracy of its assessment decisions and to take corrective actions, where threats to objectivity have been identified. The OFC supports this commitment.

Suggestions for continuous improvement

Continue to develop a formal methodology to monitor and take corrective actions, as needed, to improve the consistency and accuracy of assessment decisions.

11. The regulator prohibits discrimination and informs assessors about the need to avoid bias in the assessment. [Impartiality]

Assessment Outcome

Partially Demonstrated

OFC Comments

When assessing this practice, the OFC was seeking evidence that the College both identifies and documents:

• Characteristics and sources of bias;
• Circumstances that may compromise impartial assessment decisions; and
• The steps assessors need to take if they find themselves in these situations.

The OFC was also looking to verify that the College prohibits discrimination in the assessment of qualifications.

The OFC found that the College has a Conflict of Interest Policy in place for all employees, Council and committee members. The policy requires that all staff and members declare any potential conflicts of interest before commencing meetings and making assessment or registration decisions. While the Conflict of Interest Policy is an important tool, the OFC noted that the policy does not address other types or sources of bias that may potentially lead to biased assessment decisions.

The College explained that they additionally provide training to those involved in assessment and registration decisions that describes what constitutes a conflict of interest, how to avoid such situations, and what steps to take to declare any potential conflicts of interest. Legal counsel is also consulted on an as needed basis to address matters relating to impartial decision-making.

The College informed the OFC that they will continue to develop guidelines for internal reviewers, Council and committee members that address other types and sources of bias and provide training on managing cultural differences and building an inclusive regulatory environment. At the time of writing this report, however, the College had not yet provided sufficient evidence to show how it documents and informs assessors about other types and sources of bias, circumstances that may compromise impartial assessment decisions, and anti-discriminatory assessment practices.

Recommendations

Continue to develop guidelines, policies or other similar documents for those involved in the assessment of qualifications about the potential for bias or risk to impartiality in the assessment process. These documents should include content on:

• Characteristics or types of bias and/or situations that may compromise the impartiality of assessment decisions;
• Procedures to follow where there is a potential for bias; and
• Actions to prevent discriminatory assessment practices.

12. The regulator implements procedures to safeguard the impartiality of its assessment methods and procedures. [Impartiality]

Assessment Outcome

Partially Demonstrated

OFC Comments

This practice requires identifying and assessing measures a regulator takes to avoid or minimize bias in its assessment decisions, to verify the impartiality of its decisions, and to implement corrective actions if needed.

As previously reported, the College informed the OFC that they take some measures to avoid or prevent bias in assessment decisions, including identifying conflicts of interest amongst registration staff, Council and committee members, referring to legal counsel if issues need to be discussed, and providing training on conflict of interest as it relates to the decision-making process. While these are important actions to take, the OFC finds that these measures alone do not appear to be sufficient to safeguard the impartiality of assessment decisions. The OFC recommends that the College take additional steps to monitor assessment procedures to find potential sources of impartiality, and to identify and implement corrective actions as necessary.

Recommendations

Implement procedures to conduct a risk assessment or ongoing review process to:

• Identify potential bias in assessment methods or procedures;
• Develop and record mitigating strategies to address potential risks in guidelines for assessors and decision-makers; and
• Establish a means to ensure corrective actions are implemented in a timely manner.

13. The regulator gives applicants an opportunity to appeal the results of a qualifications assessment or to have the results reviewed. [Fairness]

Assessment Outcome

Demonstrated

14. The regulator assesses qualifications, communicates results to applicants, and provides written reasons for unsuccessful applicants, without undue delay. [Fairness]

Assessment Outcome

Demonstrated

OFC Comments

In its online information on the SECA process, the College states that it requires 3 to 6 months to complete and communicate assessment results to applicants. The College informed the OFC that they take measures to follow and monitor this timeline for processing SECA applications. These measures include monitoring submissions on a weekly basis to ensure that applications continue to move forward to the next appropriate step in the process by registration staff and the Registrar, and following up on incomplete applications in a prompt manner.

The OFC understands that the College has not yet developed an automated tool or process by which to monitor adherence to its timelines. At the time of reporting, the College informed the OFC that they have long-term plans to develop a database system to further streamline the tracking of applications through the assessment process. The OFC supports this commitment.

Suggestions for continuous improvement

Continue to develop and implement a formal and structured process to monitor established timelines for assessing qualifications and communicating results to applicants as part of the SECA process.

15. Regulators that rely on third-party assessments establish policies and procedures to hold third-party assessors accountable for ensuring that assessments are transparent, objective, impartial and fair. [Transparency, Objectivity, Impartiality, Fairness]

Assessment Outcome

Partially Demonstrated

OFC Comments

The College relies on Human Resource Systems Group Ltd. (HRSG) to conduct the IA process, which is a requirement for all applicants who are eligible for registration. The College takes measures to monitor and evaluate HRSG’s practices, including maintaining a written service agreement, providing approvals for all forms, assessment tools and applicant materials used by the third-party, and attending assessor training sessions. The College also meets with the third-party assessor at least once per year to address applicant complaints and any increases in demand for IA-related appeals. Other activities used to monitor HRSG’s assessment practices include maintaining staff-to-staff contact, exchanging weekly progress reports, and conducting periodic check-ins to promptly address any new or arising issues.

The College uses language assessment results from the Centre for Canadian Language Benchmarks (CCLB) to determine an applicant’s language fluency in English or French, where needed to meet registration requirements. The College reported that they have yet to use the services of CCLB to conduct a language assessment and do not currently have a formal process in place to monitor their assessment practices. However, the College informed the OFC that they will develop a formal and structured annual review process for this third-party assessor to ensure that their assessment practices are transparent, objective, impartial and fair. The OFC supports this commitment.

Recommendations

Develop and implement a formal and structured process to verify that third-parties’ assessment practices are transparent, objective, impartial and fair. The process should include procedures to:

• Evaluate and monitor third-parties’ assessment practices; and
• Identify potential issues and, if any issues are identified, take actions to address them.

7. Specific Duty — Training

RHPA, Schedule 2, s. 22.4(3)

1. The regulator provides training for staff and volunteers who assess qualifications or make registration, internal review or appeal decisions. [Objectivity, Impartiality, Fairness]

Assessment Outcome

Partially Demonstrated

OFC Comments

When assessing this practice, the OFC was seeking evidence that the College both identifies and provides its staff and committee members with training opportunities that address the following topics, where appropriate to their duties and responsibilities:

• How to assess qualifications and make registration decisions;
• How to make internal review and appeals decisions; and
• How to identify and apply special considerations in the assessment of applications.

The College provides both informal and formal training opportunities to their staff, Council and committee members. For example, the College reported that committee members receive training and orientation on an annual basis and staff members engage in ongoing training, as needed.

The OFC found in its assessment, however, that the College does not have a formal and structured process in place to identify and provide training to staff, committee members and others involved in assessment, registration and internal reviews processes. At the time of reporting, the College informed the OFC that they have plans to implement a regular training schedule for individuals involved in the registration process. As part of this training strategy, the College proposes to consult with other regulators on best practices and experiences. The OFC supports this commitment.

Recommendations

Develop a formal and structured process to identify and deliver training to those individuals involved in assessing qualifications, making registration decisions, making internal review decisions, and identifying and applying specials considerations in the assessment of applicants.

2. The regulator addresses topics of objectivity and impartiality in the training it provides to assessors and decision-makers. [Objectivity, Impartiality]

Assessment Outcome

Partially Demonstrated

OFC Comments

When assessing this practice, the OFC was looking for evidence that the College provides its staff and committee members with training opportunities that address:

• Anti-discrimination;
• Cultural diversity;
• The objectives of the fair-access law; and
• Objective and impartial decision-making and what it means in the context of the registration process.

The College has reported that legal counsel provides their committee members with training on fair-access law and objective and impartial decision-making. However, it is not evident to the OFC whether this training for committee members takes into consideration anti-discriminatory practices and provides content on cultural diversity. It is also not clear to the OFC whether staff at the College involved in the assessment and registration processes receive training on the topics listed above.

Recommendations

Develop and implement training opportunities for staff and committee members involved in assessment and registration decisions that address the following topics:

• Anti-discrimination;
• Cultural diversity;
• Objectives of fair-access law; and
• Objective and impartial decision-making and what it means in the context of the registration process.

3. The regulator identifies when new and incumbent staff and volunteers require training and provides the training accordingly. [Objectivity, Impartiality, Fairness]

Assessment Outcome

Not Demonstrated

OFC Comments

When assessing this practice, the OFC was seeking evidence that the College has a process to identify when new and incumbent staff and committee members require training, to set timelines for training, and to verify whether training was completed as per the established timelines.

The College has reported that committee members involved in the registration process are provided with orientation training on their duties and responsibilities. Registration staff, Council and committee members also receive ongoing training to address any identified individual or group training needs. The College stated that most training sessions are recorded in meeting minutes or included in staff members’ individual personnel files. While these are important actions to take, the OFC finds that the College does not currently have a planned and organized process to determine when and how staff and committee members receive training, to set timelines for providing the training, and to verify that the training occurs within established timelines. As previously noted, the College has plans to implement a regular training schedule for individuals involved in the registration process.

Recommendations

Develop guidelines, policies or other similar documents for onboarding and ongoing training of staff and committee members. Include procedures for:

• Identifying when new and/or incumbent staff and committee members require training;
• Establishing timelines for the completion of training; and
• Verifying that training has been completed according to these timelines.

8. Specific Duty — Access to Records

RHPA, Schedule 2, s. 16

1. The regulator provides each applicant with access to his or her application records. [Fairness]

Assessment Outcome

Demonstrated

2. If there is a fee for making records available, the regulator gives applicants an estimate of this fee. [Transparency]

Assessment Outcome

Not Applicable

OFC Comments

The College does not have a fee for making records available to applicants.

3. If there is a fee for making records available, the regulator review the fee to ensure that it does not exceed the amount of reasonable cost recovery. [Fairness]

Assessment Outcome

Not Applicable

OFC Comments

The College does not have a fee for making records available to applicants.

General Duty

RHPA, Schedule 2, S.22.2

Transparency

• Maintaining openness
• Providing access to, monitoring, and updating registration information
• Communicating clearly with applicants about their status

Assessment Outcome

The College takes a number of practical measures to achieve transparent registration practices, which have been outlined below. To take these efforts even further, the OFC identified one recommendation and one suggestion for continuous improvement as outlined below.

Openness

The College implements various means to enable interested stakeholders to understand how the registration process operates and how registration decisions are made. The College’s actions include:

• Providing detailed information and documentation on its website about registration requirements and processes, including application forms, guides, factsheets, frequently asked questions, and flowcharts;
• Facilitating group and individualized information sessions for applicants to increase their understanding of the IA, registration processes and requirements;
• Conducting public consultations to gather feedback from interested stakeholders on program development, registration requirements and fees, and by-law changes;
• Posting council meeting agendas and supporting materials on their website and informing interested stakeholders about up and coming meetings; and
• Providing access to annual reports, distributing e-mail blasts to interested stakeholders, and publishing a bi-monthly e-newsletter, “Rubrics”.

While it is evident that the College has numerous structures and processes already in place to promote transparency, the OFC was also seeking evidence that the College takes measures to elicit feedback from applicants and members about their pre-assessment and registration experiences and to use this input where possible to improve the overall registration process. The OFC was not able to find sufficient evidence of this action.

Access

The College ensures that applicants have access to relevant information at the time and in the way they need to take the appropriate steps in the registration process. For example, the College provides applicants for the SECA process and the IA with a range of resources as well as in-person supports to help them best prepare their applications. The College`s website also provides applicants with information on exemptible registration requirements and the notarization of documents.

With respect to fees, the OFC found that the College provides most fees associated with the SECA and registration processes in its guide to registration and SECA flowchart. The OFC found, however, that information between the two resources was not always clearly aligned. For example, the guide refers to the fee for the Individual Prior Learning Assessment, while the flowchart references the IA fee for cases and essay. The College also specifies in these materials that there may be related costs that applicants need to consider, including fees to obtain transcripts, certificates of professional standing and insurance. However, the College does not make reference to potential costs for third-party language assessments and the notarization of documents in SECA resources. For further transparency for all applicants, it may be helpful for the College to develop a consolidated fees schedule on its website that details all costs associated with the SECA and registration processes.

Clarity

The College takes measures to communicate with applicants throughout the registration process and to ensure that the information provided is complete, accurate and easy to understand. For instance, the College:

• Provides applicants undergoing the SECA process with a progress report on their file every four weeks;
• Notifies applicants about missing information and supporting documentation until the application for registration is complete; and
• Informs applicants about any delays in the registration process.

Recommendations

Implement a formal and structured process to seek feedback from applicants and members on their experiences with the SECA and registration processes. Incorporate feedback where appropriate in discussions about registration policy and practices.

Suggestions for continuous improvement

Develop an online fees schedule that outlines all costs to applicants in the SECA and registration processes, including related costs not under the regulator’s control that an applicant may need to consider in completing the process. Provide references to this schedule in information for applicants and registration materials.

Commendable practices

Allowing applicants the opportunity to complete the various steps in the pre-assessment and registration processes in any order and to also complete several of the steps concurrently. This increased flexibility enables applicants to more efficiently complete the various steps required.

Providing information sessions on the IA process in collaboration with the third-party assessor to help applicants better understand the competencies being assessed and how to prepare materials for their assessment submissions.

Objectivity

• Designing criteria and procedures that are reliable and valid
• Monitoring and following up threats to validity and reliability

Assessment Outcome

The College takes a few of the required measures to achieve objectivity in its registration process. For further development, the OFC identified four recommendations below.

Reliability

To ensure that registration decisions are reliable, the College:

• Provides decision-makers with access to a range of policy documents and registration materials to promote consistent and accurate registration decisions;
• Conducts training for decision-makers to support a shared understanding of their duties and responsibilities in the registration process; and
• Provides decision-makers with a resource binder and copies of all past decisions and reasons for their reference.

While the College takes steps to ensure that its decision-makers have access to criteria, policies and procedures to do their work, the OFC noted that formal guidelines for decision-makers were not provided in policy documents for all registration requirements. Specifically, the OFC did not find evidence of formal guidelines to assess the good character/professional conduct and criminal background check requirements, in cases where further evaluation by the College is necessary.

In assessing this general duty principle, the OFC was also seeking documented evidence that the College has formal and structured processes to review and update statements describing registration requirements for clarity, and to inform decision-makers about changes to this information in a timely manner. Furthermore, the OFC was aiming to confirm whether the College takes measures to ensure that decision-makers consistently apply registration requirement criteria, policies and procedures to all applicants. For instance, the OFC was looking for evidence of documented guidelines, templates or other similar tools that decision-makers are required to use to ensure that collected evidence is interpreted in a consistent manner, such as for decisions made about an applicant’s character / past registration. The OFC did not find sufficient evidence of such actions.

Validity

To ensure that the College takes measures to monitor the objectivity of its registration decisions, the OFC was seeking evidence that the regulator has processes in place to verify the consistency and accuracy of its decisions and to identify and implement corrective actions, as needed. The OFC did not find sufficient evidence of these actions.

Recommendations

Develop and implement a work plan to document formal guidelines explaining the decision-making steps and procedures to consistently and accurately apply criteria for the good character and criminal reference check registration requirements.

Develop formal procedures to inform decision-makers of any changes to registration criteria, policies and procedures to ensure that they are given information that is current and relevant in a timely manner.

Implement measures to safeguard and promote consistency in registration decisions. For example, continue to develop and refine guidelines and tools that require decision-makers to follow the same step sequence in applying registration requirement criteria, policies and procedures to all applicants.

Develop and implement measures to monitor, verify and improve the consistency and accuracy of registration decisions. Measures may include a periodic review of registration decision trends by a designated staff member or a standing agenda item for the registration committee to discuss past decisions.

Impartiality

• Identifying bias, monitoring, and taking corrective action
• Implementing strategies

Assessment Outcome

The College takes some measures to achieve impartiality in its registration process. To take these efforts even further, the OFC identified four recommendations below.

Identification of Bias

The College implements measures to document and inform decision-makers about the need to avoid bias in its registration decisions. For example, the College provides staff and committee members with orientation and training on what constitutes a conflict of interest and the steps to follow if they find themselves in a position of conflict. The College also stated that it requires staff and committee members to declare any conflicts of interest at the start of every meeting and before reviewing each application for registration. When assessing this general duty principle, however, the OFC was also seeking to verify that the College takes actions to address other types and sources of bias, other than conflict of interest, with staff and committee members that may compromise impartial decision-making. At present, sufficient evidence of these actions was not found.

The OFC was also looking for evidence that the College takes formal measures to monitor its decision-making process to ensure that decisions are made in the public interest and are not influenced by internal or external factors. Such measures include:

• Having a process to consider internal or external factors that may improperly influence policy or individual case decisions and to determine what actions are needed for impartial decision-making;
• Considering why a policy change is in the public interest and/or what issues it intends to resolve; and
• Exploring what positive and/or negative impacts the policy change may have on those affected by it.

The OFC did not find sufficient evidence of these actions.

Strategies

The College implements the following strategies to avoid bias in its decision-making:

• Provides staff and committee members with informal and formal training on the principles of transparency, objectivity, impartiality and fairness; and
• Directs its decision-makers to commit to bias-free registration practices.

When assessing this general duty principle, the OFC was also looking for confirmation that the College has procedures in place to:

• Avoid or minimize bias in registration decisions;
• Monitor decision-making procedures to identify sources of impartiality; and
• Identify and implement corrective actions as necessary.

As well, the OFC was seeking evidence that the College has guidelines, policies or other similar documents in place to assure that staff and committee members commit to bias- and discrimination-free registration practices.

The OFC did not find sufficient evidence of these actions.

Recommendations

In documents, such as policies, guidelines and codes of conduct, for staff and committee members involved in registration and internal reviews processes:

• Document characteristics and sources of bias and/or situation that may compromise the impartiality of registration decisions;
• Provide strategies to manage situations of bias; and
• Outline conduct to follow for decision-making that is impartial and free of discrimination.

Develop guidelines for making registration policy decisions that include steps to identify and address any internal and/or external factors that may improperly influence decisions.

Implement control procedures to avoid or minimize bias, to monitor and identify potential sources of bias, and to take corrective actions as needed for impartial decision-making.

Develop a code of conduct that commits decision-makers to bias- and discrimination-free registration practices.

Fairness

• Ensuring substantive fairness
• Ensuring procedural fairness
• Ensuring relational fairness

Assessment Outcome

The College takes a number of reasonable measures to promote fairness in its registration practices. To take these efforts further, the OFC has identified four recommendations and two suggestions for continuous improvement below.

Substantive Fairness

The College takes the following actions to promote substantive fairness:

• Offers the SECA process to applicants that have not completed an approved educational program in homeopathy as a means to demonstrate their eligibility to register with the College;
• Maps each registration requirement to the specific competencies or set of competencies that it addresses in information for applicants and registration materials; and
• Provides a rationale for the amount of fees under its control and undergoes a periodic review for the purpose of identifying the reasonableness of its fees.

When assessing this general duty principle, the OFC was also looking for evidence that the College has a process to periodically review registration requirements to ensure that they continue to be relevant and necessary to professional practice. The OFC was not able to find sufficient evidence of this action.

Procedural Fairness

The College takes steps to support procedural fairness in its registration practices, including:

• Providing individualized supports to applicants undergoing the SECA and IA processes to ensure that all required information and supporting documentation is included in their applications;
• Reviewing its registration practices to identify opportunities for improvements and streamlining (for example, waiving the health care provider CPR requirement and aligning the insurance requirement with other health profession regulators for dual registrants); and
• Informing applicants about potential delays and estimated timelines for decisions, where delays are unavoidable, throughout the pre-assessment and registration processes.

While the College takes measures as described above to promote procedural fairness, the OFC was also looking for evidence that the College has processes to ensure that registration decisions comply with criteria, policies and procedures, and to take corrective actions where deviations have been identified. The OFC was not able to find sufficient evidence of these actions.

Furthermore, the OFC was seeking verification that the College has procedures in place to ensure that decision-makers adhere to established timelines for making and communicating decisions and reasons to applicants, responding to applicant inquiries and requests, providing applicants with access to internal reviews of assessment decisions, and making and communicating internal review decisions to applicants. The OFC did not find sufficient evidence of these actions.

As part of the SECA process, applicants are required to complete a pre-registration form that requests information on their education and experience. The OFC noted that the application for registration form asks applicants to provide duplicate information. It is unclear to the OFC whether applicants that have been successful in the SECA process are required to again provide these details when they register. For continuous improvement in its registration practices, the College might consider reviewing and streamlining the application for registration form for applicants that have successfully undergone the SECA process.

Relational Fairness

The College takes several measures to ensure relational fairness for its applicants during the registration process. For example, the College has documented procedures to consider and provide alternatives in cases where applicants cannot obtain required documentation for reasons beyond their control.

In 2017, the College’s Registration Committee approved a refresher program for applicants whose qualifications assessments identified gaps in their education and/or clinical training. The refresher program provides applicants with an alternative way to meet the currency requirement for clinical experience, training or education and gaps in some competency areas. The program is administrated by a third-party College-approved homeopathic education provider. Information on the refresher program can be found as part of the College’s online information for applicants and registration materials.

The College also informs applicants in its pre-assessment and registration materials of the opportunity to request special accommodations if they experience challenges in completing assessment and application requirements. The College indicates that requests are considered on a case-by-case basis and may take several weeks to be reviewed and either approved or denied. The OFC understands that the College receives few requests from applicants for special accommodations and, therefore, it is reasonable that these requests are handled individually. However, it is important that the College have a set of procedures to follow when special accommodations are required as part of the pre-assessment and registration processes to avoid subjectivity in these decisions. Documented procedures should include the steps an applicant needs to take to make a request, the process by which decision-makers take an applicant’s circumstances into consideration, and actions the College may take to accommodate an applicant’s request. The College might also consider reviewing the process for considering such requests with the intention to shorten the time required to provide applicants with the accommodations they need to fully engage in the registration process.

Recommendations

Develop and implement procedures for a scheduled review of registration requirements to verify that these requirements remain relevant and necessary to practice in the profession.

Develop an internal audit process that will:

• Identify registration decisions that are in compliance and non-compliance with established registration criteria, policies and procedures;
• Identify the potential causes of non-compliance; and
• Provide guidelines for implementing corrective actions, as needed.

Develop and implement monitoring processes to ensure that decision-makers adhere to established timelines for:

• Making and communicating decisions and reasons to applicants;
• Responding to applicants’ inquiries or requests;
• Providing applicants with access to internal reviews of assessment decisions; and
• Making and communicating decisions about internal reviews.

Develop a set of procedures to consider requests for special accommodation from applicants undergoing the pre-assessment and registration processes and possible actions the College may take to accommodate requests. Include reference to these documented procedures in information for applicants and registration materials.

Suggestions for continuous improvement

Review and streamline the application for registration form for applicants that have successfully undergone the SECA process to exclude requests for information that was previously provided.

Review the timelines for considering requests for special accommodations to ensure that applicants have access to accommodations within a reasonable time.

Commendable practices

Pro-rating registration fees for the first year of membership and providing applicants with a need for accommodation option to pay by installment.

Approving a competency-based and clinical supervision refresher program for applicants who demonstrated gaps in their education and/or clinical training and are unable to meet registration requirements.

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Background

Assessment Methods

Assessments are based on the Registration Practices Assessment Guide: For Regulated Professions and Health Regulatory Colleges. The guide presents registration practices relating to the specific duties and general duty in the fair access legislation.

A regulatory body’s practices can be measured against the fair access legislation’s specific duties in a straightforward way. However, the general duty is broad, and the principles it mentions (transparency, objectivity, impartiality and fairness) are not defined in the legislation.

As a result, the specific-duty and general-duty obligations are assessed differently (see the Strategy for Continuous Improvement of Registration Practices).

Specific Duties

The OFC can clearly determine whether a regulatory body demonstrates the specific-duty practices in the assessment guide. Therefore, for each specific-duty practice, the OFC provides one of the following assessment outcomes:

• Demonstrated – all required elements of the practice are present or addressed
• Partially Demonstrated – some but not all required elements are present or addressed
• Not Demonstrated – none of the required elements are present or addressed
• Not Applicable – this practice does not apply to the College

General Duty

Because there are many ways that a regulatory body can demonstrate that its practices, overall, are meeting the principles of the general duty, the OFC makes assessment comments for the general duty, rather than identifying assessment outcomes. For the same reason, assessment comments are made by principle, rather than by practice.

For information about the OFC's interpretations of the general-duty principles and the practices that the OFC uses as a guideline for assessment, see the OFC's website.

Commendable Practices and Recommendations

Where applicable, the OFC identifies commendable practices or recommendations for improvement related to the specific duties and general duty.

Sources

Assessment outcomes, comments, and commendable practices and recommendations are based on information provided by the regulatory body. The OFC relies on the accuracy of this information to produce the assessment report. The OFC compiles registration information from sources such as the following:

• Fair Registration Practices Reports, audits, Entry-to-Practice Review Reports, annual meetings
• the regulatory body's:
  • website
  • policies, procedures, guidelines and related documentation templates for communication with applicants
  • regulations and bylaws
  • internal auditing and reporting mechanisms
  • third-party agreements and related monitoring or reporting documentation
  • qualifications assessments and related documentation
• targeted questions/requests for evidence that the regulatory body demonstrates a practice or principle

For more information about the assessment cycle, assessment process, and legislative obligations, see the Strategy for Continuous Improvement.

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References

1. ^ Please note: Suggestions for continuous improvement appear only in the detailed report. Suggestions for improvement are not intended to be recommendations for action to demonstrate a practice, but are made solely to provide suggestions for areas that a regulatory body may consider improving in the future.