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In December 2013, Ontario’s Office of the Fairness Commissioner (OFC) performed a targeted assessment of the way the College of Physicians and Surgeons of Ontario (CPSO) 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.


Focus of This Assessment and Report

The December 2013 targeted assessment of the CPSO focused on the areas where the OFC made recommendations in the full assessment it completed in March 2012.

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

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


Availability of Report

The OFC encourages the CPSO 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.


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.


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.


Assessment Summary

Specific Duties

Specific duties assessed

As a result of the recommendations made in the full assessment completed in March 2012, the CPSO has been assessed in the area(s) marked below:

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


General Duty

Assessment Method

The CPSO 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

As a result of the recommendations made in the full assessment completed in March 2012, the CPSO has been assessed on the principle(s) marked below:

None Unchecked
Transparency Checked
Objectivity Unchecked
Impartiality Unchecked
Fairness Checked


The OFC found that since the last assessment, the College of Physicians and Surgeons of Ontario (CPSO) has taken active measures to promote transparency and fairness. Recommendations for further improvement are listed below.


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


  • developing flowcharts to explain the options available to applicants based on their current situation (practising in other provinces and territories, practising in the US, practising elsewhere, or non-practising and internationally educated). This helps to provide an overview of a complex licensing system. 
  • introducing a system to allow applicants to check the status of their application online. Applicants can easily see whether required documents have been received and can follow up in a timely manner.
  • implementing a “case coordinator” model to improve communication with applicants. Applicants know who is responsible for processing their application and can communicate directly with this person. 
  • providing detailed information about registration committee deadlines and meeting dates. This provides affected applicants with a clear timeline for consideration of their case.


  • carrying out an efficiency initiative to streamline communication and processing of applications. As a result, the CPSO has experienced a decrease in service timelines: from 7 to 4 weeks for traditional pathways to registration, and from 15 to 5 weeks for complex applications that have to be referred to the registration committee.
  • ensuring the continued quality of decision-making after implementation of the efficiency initiative, by auditing 10% of all applications.



The CPSO should continue to strive for excellence in the following areas.


  • Implement communication strategies to:
December 2014
  • alert potential applicants about the complexity, length and cost of the licensing process
December 2014
  • provide information about steps that internationally educated applicants can complete before they arrive in Canada
December 2014
  • Provide more information and practical instructions about the supervision and assessment process for people who are applying under registration policies that offer alternatives to the usual registration requirements. 
December 2014


  • Be mindful of the emerging data about match rates for Canadians studying abroad and other international medical graduates (IMGs) in any future discussions with external stakeholders who are accountable for the postgraduate matching process.
November 2015 
  • Continue to explore possible policies for expanding routes to registration for qualified applicants.
November 2015 
  • Encourage the Ministry of Health and Long-Term Care to work with other relevant stakeholders to develop capacity to provide additional practice-ready assessment and training positions for family and specialty medicine.
November 2015
  • Encourage stakeholders to consider a pilot project for practice- ready assessment in a community-based setting that would meet national standards for this purpose. 
  • Provide information about non-clinical opportunities such as research fellowships and observerships that may help internationally educated applicants to familiarize themselves with the Ontario healthcare system.
December 2014
  • Increase the visibility of the policy statement on delegation of controlled acts, and provide explanatory content in the IMG section of the website to more explicitly address the issue of delegation to internationally educated physicians. This will help internationally educated physicians understand how the delegation policy works and how they may benefit from it.
December 2014
Blank = Implementation is in progress.
Checked = Recommendation is implemented.
Acceptable alternative = Regulator implements acceptable alternative to this recommendation.

Assessment History

In the previous assessment, the OFC identified six recommendations for this regulatory body.

They have all been implemented.