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Introduction

In September 2014, Ontario’s Office of the Fairness Commissioner (OFC) performed a full assessment of the way the College of Denturists of Ontario (CDO) registers people who apply for a licence to practise in Ontario, to ensure that the registration practices are fair and continue to improve.

Assessment is one of the Fairness Commissioner's mandated roles under the Regulated Health Professions Act, 1991 (RHPA).

Assessment Cycle

To hold regulatory bodies accountable for continuous improvement, the OFC assesses their licensing practices using a two-year assessment cycle.

Assessment cycles alternate between full assessments and targeted assessments:

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

This approach establishes continuity between the assessment cycles.

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Focus of This Assessment and Report

In the OFC's 2011–12 assessment cycle (which consisted of full assessments), the OFC did not assess the CDO. The CDO was undergoing the Ministry of Health and Long-Term Care's Operational Review and Audit, the scope of which included the CDO's registration practices. Therefore, this 2014 assessment is a full assessment of all general-duty and specific-duty areas.

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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Availability of Report

The OFC encourages the CDO to provide the detailed report to its staff, council members, the public, and other interested parties.

To receive a copy of the detailed report, click here.

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Assessment Methods

Assessments are based on the Registration Practices Assessment Guide – For 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 this regulatory body

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 Registration Practices Assessment Guide – For Health Regulatory Colleges.

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 of Registration Practices.

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Assessment Summary

Specific Duties

Specific duties assessed

The CDO has been assessed in the area(s) marked below:

None Unchecked
Information for Applicants Checked
Internal Review or Appeal Checked
Information on Appeal Rights Checked
Documentation of Qualifications Checked
Assessment of Qualifications Checked
Training Checked
Access to Records Checked

Outcomes

The CDO has demonstrated all of the practices in the following specific-duty area(s).

  • Internal "Review"
  • Information on Appeal Rights

For practices that are partially demonstrated or not demonstrated, see the Recommendations section later in this summary.

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General Duty

Assessment Method

The CDO selected the method marked below for the assessing of its adherence to the general-duty principles, and informed the OFC:

a. OFC assesses based on the practices listed in the assessment guide Checked
b. Regulatory body self-assesses based on the practices in the assessment guide Unchecked
c. Regulatory body self-assesses using a system-based approach, in which it explains what it does to ensure that its practices are adhering to the general-duty principles Unchecked

Principles assessed

The CDO has been assessed on the principle(s) marked below:

None Unchecked
Transparency Checked
Objectivity Checked
Impartiality Checked
Fairness Checked

Comments

The OFC found that the CDO is demonstrating some efforts to toward transparency, objectivity, impartiality and fairness. Recommendations for further improvement are listed below.

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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 CDO is demonstrating commendable practices in the following area(s).

Fairness

  • developing a Criminal Records and Offence Declaration Policy to explain its approach to handling evidence of conduct. The policy includes the CDO’s underlying principles, explains the need for a conduct requirement, and explains the need for the CDO to justify its decisions with evidence.
  • developing a policy for dealing with insufficient or incomplete documentation. The policy identifies the circumstances where this policy may apply, the steps that applicants and the registration committee will take, and the types of alternative documentation that would be considered.

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Recommendations

The CDO should improve in the following area(s):

Information for Applicants

Status
  • Develop a consistent internal process to ensure the completeness and accuracy of information about the CDO’s registration requirements, process and timelines. (Practice 1.1, 1.2, 1.3)
 
  • Provide more information about the following:
 
  • the possible outcomes for the educational assessment (Practice 1.2)
Checked
March 2015
  • how long the registration process (including the time required for qualifications assessment) usually takes (Practice 1.3)
Checked
March 2015

Documentation of Qualifications

 
  • Develop a consistent internal process for ensuring the completeness and accuracy of information about the documentation that applicants must provide. (Practice 4.1)
Checked
June 2015
  • Address the clarity and comprehensiveness of information about the required documentation by:
 
  • providing more information about the required content for the documentation that applicants must provide to show that they meet the educational requirement (e.g., content for the transcript (individual courses),  diploma, and credential report from the credentialing agency)
 
  • providing information about the required format of the transcript and credential report, and how they must be sent to the CDO
 
  • indicating whether applicants who have provided educational documentation (transcript, diploma, etc.) to the third-party assessment agency must also submit this educational documentation again to the CDO or whether the CDO would accept documentation accepted by the credentialing agency. During this assessment, the CDO was amending its processes to reduce the amount of documentation required from applicants. This clarification may be particularly helpful to applicants for whom translations and educational documentation are expensive or resource-intensive to obtain. (Practice 4.1)
 

Assessment of Qualifications

 
  • Provide evidence that the CDO has documented guidance for how the criteria identified for assessing qualifications are to be judged/interpreted by assessors and decision-makers, as follows:
Checked
March 2015
  • For the educational equivalency assessment, provide evidence of documented guidance about:
 
  • how to apply the criteria for identifying which applicants undergo an assessment
 
  • how to use the templates to make a determination
 
  • what factors are to be considered for each program reviewed. (E.g.: For the program: level of education, entrance requirements, length of the program, the materials or practical experience to be included in the program. For courses: the level at which they must be assessed, minimum hours of study, mode of delivery, breadth and depth of material covered.)
 
  • For exams, provide evidence that examiners/markers are given evaluation tools to help them interpret the criteria for the exams.*
 
  • The CDO should also have a way to document its planning process for its qualifications assessments so that everyone understands under what circumstances the existing criteria might need to be reviewed and updated. (Practice 5.1)
 
  • Provide evidence of the linkage between the competency profile and:
 
  • academic criteria
 
  • assessment of language – in particular, language scores
 
  • passing score for exams* (Practice 5.2)
 
  • Ensure greater consistency in applying qualifications assessment criteria by:
 
  • recording guidance
 
  • providing sufficient training
 
  • developing ways to monitor adherence to policies and processes (Practice 5.3)
 
  • Provide evidence to clarify how the CDO ensures that the information it has about educational programs is recorded and kept current and accurate. (Practice 5.4)
Checked
August 2015
  • Provide evidence of a sustainable structure for reviewing each of the CDO’s assessment methods (academic-equivalency assessment, language assessment, and exams) for objectivity, validity and reliability at periodic intervals. The review should address the criteria, tools, training and procedures for each assessment method. (Practice 5.5)
 
  • Address gaps in the information that is available to applicants about the qualifications assessments. On the CDO website, provide the following information about:
 
  • CDO’s exams:
 
  • the criteria that the exams are based on (e.g., passing scores)
 
  • opportunities to appeal the results of the exams or have the results reviewed
 
  • how its other qualifications assessments are linked to the national competency profile, including the language assessment tests and scores and the educational equivalency criteria
 
  • any policies and procedures relating to special considerations for the educational equivalency assessment  
 
  • In addition, develop a consistent internal process to ensure that the information about each qualifications assessment is complete, current, and accurate. (Practice 5.8)
Checked
April 2015
  • Provide evidence of set timelines, and a formalized process for monitoring and ensuring adherence to those set timelines, for:
 
  • assessing qualifications
 
  • communicating results
 
  • providing reasons for the educational equivalency assessment process and the new exam processes (Practice 5.9)
 
  • Develop a process or agreement for each of the CDO’s third-party assessment agencies, to ensure that each has transparent, objective, impartial and fair practices.(Practice 5.10)
Checked
December 2014

Training

 
  • Provide evidence that the CDO’s assessors and decision-makers are trained in how to address special considerations, especially if special considerations are handled on a case-by-case basis. The training needs to cover when the special considerations apply (during the assessment and decision-making processes) and the process to address requests for special considerations. (Practice 6.2)
Checked
December 2014

Access to Records

 
  • Formally record the CDO’s rules and process for addressing an applicant request for access to records. (Practice 7.1)
Checked
March 2015

Transparency

 
  • Provide evidence of (or, if not in place, develop) a registration manual (or other resource documentation) that would enable CDO staff to consistently:
 
  • provide information to applicants about registration
 
  • take the appropriate internal steps when processing an applicant
 
  • know when, what, and how to communicate with applicants at each stage of the registration process
 
  • Include in the registration materials on the CDO website:
Checked
March 2015
  • all the steps in the registration process that an applicant can do or start outside of Canada, such as qualifications assessment (i.e., educational equivalency assessment, language assessment, and exams). If the CDO relies solely on the career map to identify this information, it should ensure that the map is current and accurate.
Checked
March 2015
  • all possible costs that an applicant may incur while completing the registration process. (Or, clearly describe where the applicant can learn about these costs.) The costs include those associated with translation, notarizing, statutory declarations, and requests for education and other supporting documentation.
Checked
March 2015
  • the way that francophone applicants access materials in French. Either provide a statement on the website in French instructing applicants how to contact CDO for information in French, or provide online access to translated registration materials.
Checked
March 2015
  • the way in which applicants can request access to their own records, the way in which these records are available, who may access the records, how long applicants’ records are kept, and what limitations (if any) exist on the right applicants have to access their own records
  Checked
March 2015
  • information about which documents are kept by the CDO and which documents are returned to applicants upon written request
 Checked
March 2015

Objectivity

 
  • Take further steps to reduce subjectivity, by improving the specificity of the criteria used to determine educational equivalency (e.g.: number of years of study; number of hours of practical training; mode of delivery required for the course, such as in-class and/or distance education).
 
  • Develop a review process to ensure that registration criteria for the education requirement and the criteria for the language requirement are appropriate and aligned with the national competencies.
Checked
June 2015
  • Provide evidence of clear and sufficiently detailed guidelines, procedures and training to ensure consistency of decisions about:
Yearly and ongoing
  • exams
 
  • the completeness of an application
 
  • conduct
 
  • exemptions from registration requirements
 
  • advising applicants on submissions to the registration committee
 
  • While the CDO does provide some training to individuals who assess, make decisions or review decisions, it is not clear that there is a process for identifying training needs and the ways for meeting those needs. Moreover, the CDO has identified that its training for these individuals needs to be more comprehensive and in-depth.
 

Impartiality

 
  • Provide evidence that all staff members who deal with applications have training in the following:
 
  • anti-discrimination (for example: staff have been trained on the Ontario Human Rights Code; staff have been trained on internal policies related to anti-discrimination)
 
  • cultural diversity (for example: staff are trained in cultural differences and how to identify the potential for biases)
 
  • the objectives of Schedule 2 to the Health Professions Procedural Code of the RHPA
 
  • If there is no process for ensuring that staff members are trained in the areas listed in the preceding point, develop a process for identifying the individuals who require training and ensure that training in the areas identified is provided at fixed intervals.
 
  • Provide evidence of written procedures that the decision-makers adhere to for all groups of applicants. Provide evidence of the CDO’s control processes, such as different levels of access to applicant information to mitigate the potential for bias.
 
  • Provide evidence about the topics covered in the CDO’s training. The training would need to include how to apply assessment criteria for decision-making. The training would also need to include a plan to measure whether training is effective and/or a process to monitor the performance and quality of decision-makers.
Checked
December 2014

Fairness

 
  • Provide evidence that the CDO has reviewed its registration requirements against the national competencies and has demonstrated the connection. (E.g.: What are the precise competencies that the requirement is intending to prove? What evidence is it based on? Is the requirement the most feasible way of measuring the applicant’s competencies? Has the requirement been validated by experts and stakeholders?)
Checked
March 2015
  • Provide evidence that the CDO has a system for ensuring that it adheres to its own policies and procedures, in order to ensure the quality of its decisions. If there is no system in place, develop one.
Checked
September 2015
  • Make sure that documentation CDO requires from applicants is necessary. Investigate the possibility of coordinating with the third-party assessment agencies so that an applicant will only have to submit these documents to one organization (e.g., either the third-party agency or the CDO).
 
  • Document all internal processing timelines – in particular the timelines for registration committee decisions. Without set timelines, the CDO cannot adequately monitor its adherence to timelines. Develop a structure that enables CDO to monitor whether staff and decision-makers adhere to these timelines.
 

* The CDO implemented all recommendations marked with an asterisk before the OFC completed its assessment.

 
Blank = Implementation is in progress.
= Recommendation is implemented.
Acceptable alternative = Regulator implements acceptable alternative to this recommendation.

Assessment History

The OFC did not assess the CDO in the 2011–12 assessment cycle, because the CDO was undergoing the Ministry of Health and Long-Term Care’s Operational Review and Audit, the scope of which included the CDO’s registration practices.

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