Introduction

This report contains an assessment of registration practices of the Ontario College of Pharmacists.

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.

In this assessment cycle, certain practices related to provision of information are excluded as the College has previously been assessed in these areas.^[1] In most cases, regulators that have previously been assessed have demonstrated compliance with these practices and will only be assessed should substantive changes arise in policies or practices.

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Assessment Summary

The Office found the College in compliance with the OFC’s fair registration practice standards, and did not identify any recommendations in this assessment cycle.

Specific Duties

Specific duties assessed

The regulator has been assessed on all of the specific duties identified in Schedule 2 of the Regulated Health Professions Act, with the exception of practices related to the provision of information.

Comments

The regulatory body has demonstrated compliance with all of the practices in the following specific-duty areas that were assessed:

• Timely Decisions, Responses and Reasons
• Internal Reviews and Appeals
• Assessment of Qualifications
• Training
• Access to Records

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 demonstrated compliance with all of the general duty principles: transparency, objectivity, impartiality and fairness.

Comments

The OFC found that since the last assessment, the Ontario College of Pharmacists (OCP) has taken the following measures to ensure a transparent, objective, impartial and fair registration process.

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:

General Duty

Impartiality

1. The College’s Conflict of Interest policy for practical trainees and assessors in the Practice Assessment of Competency at Entry program provides clear guidance on declaring potential conflicts prior to initiating the training.

Fairness

1. Since the last assessment, the College introduced its revised structured practical training program (PACE). This program is a substantial revision to the previous program, offering flexibility in assessment, and a shorter route through the process for qualified applicants.

Opportunities for Improvement

None

Assessment History

In the previous assessment, eight recommendations were produced. They have all been implemented.

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Detailed Report^[2]

Specific Duty

1. Specific Duty — Information for Applicants

Exempt as previously assessed.

2. Specific Duty — Timely Decisions, Responses and Reasons

FARPACTA, s. 8 and s. 9 (1)
RHPA, Schedule 2, s.20 (1)
*Only applies to regulatory bodies governed by FARPACTA

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

Assessment Outcome

Demonstrated

2. The regulator makes registration decisions, and gives written decisions and reasons to applicants, without undue delay*. [Fairness]

Assessment Outcome

Not Applicable

3. The regulator responds to applicants’ inquiries or requests without undue delay*. [Fairness]

Assessment Outcome

Not Applicable

4. The regulator provides internal reviews of decisions, or appeals from decisions, without undue delay*. [Fairness]

Assessment Outcome

Not Applicable

5. The regulator makes decisions about internal reviews and appeals, and gives written decisions and reasons to applicants, without undue delay*. [Fairness]

Assessment Outcome

Not Applicable

3. Specific Duty — Internal Review or Appeal

FARPACTA, s. 7, s. 9(2-3, 5)
RHPA, Schedule 2, s. 15, s. 17, s. 19, s. 22.3
*Only applies to regulatory bodies governed by FARPACTA

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

Not Applicable

4. The regulator provides information on its website about any limits or conditions on an internal review or appeal.* [Transparency]

Assessment Outcome

Not Applicable

4. Specific Duty — Information on Appeal Rights

Exempt as previously assessed.

5. Specific Duty — Documentation of Qualifications

Exempt as previously assessed.

6. Specific Duty — Assessment of Qualifications

FARPACTA, s. 10 (2)
RHPA, Schedule 2, s. 22.4(2)
*Only applies to regulatory bodies that develop and administer their own exams.

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

Exempt as previously assessed.

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

Assessment Outcome

Demonstrated

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

Assessment Outcome

Demonstrated

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

Assessment Outcome

Demonstrated

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

Demonstrated

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

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

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

Assessment Outcome

Demonstrated

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

Assessment Outcome

Demonstrated

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

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

Demonstrated

7. Specific Duty — Training

FARPACTA, s. 11.
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

Demonstrated

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

Assessment Outcome

Demonstrated

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

Assessment Outcome

Demonstrated

8. Specific Duty — Access to Records

FARPACTA, s. 12
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

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

Demonstrated

General Duty

FARPACTA, Part II, s.6
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 recommendations listed below were submitted to the College in the 2^nd assessment cycle - all three have been implemented.

• Indicate on the OCP website when a policy serves as an alternative mechanism to meet a registration requirement.
• In the Privacy Code, include more inclusive language regarding pharmacy technician applicants.
• Closely review the OCP website to ensure that all exemptible requirements are identified.

Since the last OFC assessment, the College has made significant changes to its assessment process for internationally trained applicants.

Openness

• The new PACE assessment process (Practical Assessment of Competence at Entry) and its foundational components are featured clearly on the website.
• The College maintains a YouTube channel and Twitter feed, both of which provide information about the College’s services, policies and procedures to help applicants and interested parties understand how the College’s registration process operates.
• Registration policies explain registration criteria and evidence required to meet the criteria, and the College’s decision-making authority. Registration policies are available on the College’s website.
• Policies and decision-making criteria are readily available to staff and registration committee members. As necessary, staff members assist committee members in interpreting and applying policies.
• Policies and criteria are reviewed and updated in response to changes in the regulatory environment. Public stakeholders are consulted on changes to regulations and bylaws.

Access

• The College enables applicants to update information and complete registration transactions through an on-line account accessible on the College’s website.
• The College takes measures to ensure that applicants have all relevant information at the time and in the way needed to take actions appropriate to their individual circumstances. For example,
  • Allowing applicants to make statutory declarations should original documentation be unavailable
  • Accommodating applicants with disability in taking exams
• The College advises applicants of the progress of their application through written status updates, including application approval, examination results, and Registration Committee decisions regarding applications and requests for review.

Clarity

The College communicates effectively with applicants throughout the registration process. For example:

• Registration requirements and procedures are clearly described and explained on the website, including alternative ways in which registration requirements may be met.
• The College advises applicants of the progress of their application through written status updates.

Objectivity

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

Assessment Outcome

The College’s practices were assessed against the OFC’s standards of objectivity in 2012, and were found to meet those standards. As a result, these practices were not assessed in the second cycle in 2014.

The College uses a variety of methods to achieve objectivity in its assessment processes. These methods support a consistent approach to assessments, by promoting a shared understanding of policies, procedures and methodologies among College committees, staff and assessors. This is evident from policy documents, examples of tools for decision-makers, and information posted on the College’s website.

Reliability

To achieve consistent and reliable decisions, the College takes the following steps:

• provides annual training to all Committee members and staff involved in assessment processes
• maintains a policies and procedures manual

Validity

• In creating the PACE program, the College worked with the universities of Toronto and Waterloo, and the Ontario Hospital Residency Program to develop a common validated assessment tool to be used to assess all pharmacist applicants’ entry-to-practice competence. This assessment tool is based on impartial and transparent criteria. The College continues to work with both universities to improve the tool.

Impartiality

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

Assessment Outcome

The College’s practices were assessed against OFC standards of impartiality in the first assessment cycle in 2012, and were found to meet those standards. As a result, these practices were not assessed in the second cycle in 2014.

Identification of Bias

• The College identifies bias as it relates to conflict of interest in its staff policy manual.
• The College’s annual training for council and committee members addresses conflict of interest in context of Committee roles and responsibilities.

Strategies

The College strategies to avoid bias include:

• The College’s annual training for Council and Committee explains conflict of interest in relation to Committee roles and responsibilities.
• The College requires disclosure of conflict of interest in structured practical training arrangements where there is a familial relationship between the assessor and the trainee. The Registration Committee may permit the training to proceed upon review of the disclosure, or require the trainee to secure another arrangement.

Commendable Practice

The College’s Conflict of Interest policy for practical trainees and assessors in the PACE program provides clear guidance on declaring potential conflicts prior to initiating the training.

Fairness

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

Assessment Outcome

The College exhibits fairness in its registration practices, with evidence drawn from policies, annual reports, and FRP reports. Over the course of the previous two assessment cycles, one recommendation was produced related to fairness (below), which has been implemented.

• Provide a clear rationale for all non-exemptible requirements for registration on the OCP website.

Substantive Fairness

• Since the last assessment, the College introduced its revised structured practical training program (PACE). This program is a substantial revision to the previous program, offering flexibility in assessment, and a shorter route through the process for qualified applicants.

Procedural Fairness

• The College is undertaking a review of its policy on non-objective evidence of language proficiency, with the goal of developing a standards based framework for assessment of language proficiency at entry-to-practice.

Relational Fairness

The College takes the following actions to promote relational fairness:

• has a process for taking applicants’ circumstances into consideration
• has comprehensive policies and procedures to provide accommodations to applicants.

Commendable Practice

Since the last assessment, the College introduced its revised structured practical training program (PACE). This program is a substantial revision to the previous program, offering flexibility in assessment, and a shorter route through the process for qualified applicants.

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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 RHPA.

A regulatory body’s practices can be measured against the RHPA’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’s registration practices

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. ^ These includes: all practices from Information for Applicants, practice 3 from Internal Review and Appeals, practice 1 from Information on Appeal Rights, practice 1 from Documentation of Qualifications, practice 1 from Assessment of Qualifications, practice 2 from Access to Records, and practices 4-11 from Transparency of the Registration Practices Assessment Guide.
2. ^ 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.