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In January 2014, Ontario’s Office of the Fairness Commissioner (OFC) performed a targeted assessment of the way the College of Physiotherapists of Ontario (CPO) 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 January 2014 targeted assessment of the CPO focused on the areas where the OFC made recommendations in the full assessment it completed in January 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 CPO 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 January 2012, the CPO 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 CPO 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 January 2012, the CPO has been assessed on the principle(s) marked below:

None Unchecked
Transparency Checked
Objectivity Unchecked
Impartiality Unchecked
Fairness Unchecked


The OFC found that since the last assessment, the College of Physiotherapists of Ontario (CPO) has taken some additional measures to ensure a transparent registration process. The OFC identified two areas where the CPO needs to take further steps to ensure transparency (see the Recommendations section 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 CPO is demonstrating commendable practices in the following area(s).


  • developing and using structured and accessible mechanisms – such as an electronic policy-and-procedures manual for staff and an online portal for council members – to provide easy access to its registration policies and procedures. The purpose is to provide council members with easy access to information and resources they use frequently. The portal includes the council members’ training manual, education materials, policies, templates and other relevant material.  
  • maintaining very open governance, by including the following on its website:
    • the materials that are reviewed and decided upon in public council meetings. The website includes not only descriptive meeting updates and decision documents but also all of the meeting materials that council members need. This allows applicants and members of the public to see the CPO’s approach to documenting, reviewing, updating and approving policies that govern the CPO and affect registration.
    • “A day at the College of Physiotherapists” – a video that shows some sample cases from college committees, including the registration committee. The video discusses how the cases are reviewed, and their outcomes. It helps applicants and the public to understand the issues involved in the decision-making process.
  • monitoring the effectiveness of its policies and procedures. The CPO uses a balanced scorecard to internally measure a variety of performance indicators across the organization, including documentation, processes and procedures related to registration. It introduced this approach to help measure the elements of its performance that relate to its accountability for using competent regulatory and business practices. The CPO reviews the scorecard indicators at least once a year, and reports overall performance to the public annually.
  • launching a new website in 2012, in order to:
    • improve the accessibility of its information
    • provide additional information, including frequently asked questions (FAQs) related to registration
    • provide a checklist for internationally trained physiotherapists to identify their next steps in the registration process

Before developing the new website, the CPO conducted a member survey to evaluate its communications, including its registration information, to better understand how to improve them.



The CPO should improve in the following areas:


  • Clearly identify:
  • the steps in the registration process that an applicant can do or start outside of Canada, such as qualifications assessment, language assessment, and exams. If the CPO relies solely on the career map to identify this information, it should ensure that the map is current and accurate.
September 2014
  • possible costs that an applicant may incur while completing the registration process. (Or, clearly describe where the applicant can learn these costs.) The costs include those associated with translation, notarizing, statutory declarations, and requests for education and other supporting documentation.
September 2014

It is important that all the CPO’s registration information is current, accurate, and made available to applicants in the near future.

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 two recommendations for the regulatory body.

They have both been implemented.