As you are likely aware, Unity Health Toronto has partnered with the College of Physicians and Surgeons of Ontario (CPSO) to support active staff physicians in meeting their CPSO-mandated quality improvement (QI) requirements. Through this partnership, physicians at Unity Health have the opportunity to fulfill their five-year QI obligations by participating in a hospital-based initiative—eliminating the need to complete CPSO’s “QI for Individuals” program or undergo a college on-site assessment.
We are pleased to share the following updates about this program:

1. CPSO QI Program Requirements

Physicians who participate in the Unity Health – CPSO partnership are required to:

A. Complete two online activities on the CPSO portal:

1. Practice Profile
2. Self-Guided Chart Review

(These two online activities take an average of two hours to complete. By comparison, the ‘QI for Individuals’ stream takes an average of 12 hours to complete.)

You may have already completed these modules. If not, you will likely be asked to complete them at some point by the CPSO.

B. Engage in a hospital QI initiative at the department or division level. This includes reviewing patient experience data as a group to identify opportunities for improvement. More details are provided below. You do not need to let the CPSO know you are engaged in a hospital QI initiative. We provide a list of participating physicians to the CPSO and attest to completion.

2. Hospital QI Initiative

The Unity Health initiative focuses on understanding and improving the patient experience. Participating physicians will engage in discussions at the department or division level to:

• Review relevant patient experience data
• Identify areas for improvement
• Support the implementation of improvement initiatives.

With approval from the hospital, divisions and departments can choose a different issue

Please note: No individual physician-data will be shared internally or with the CPSO.

3. Patient Experience Data

• Annual patient experience data for inpatients and outpatients (at a medical service level) will be shared with all departments and divisions when available through the Chief or Division Head.
• Departments or divisions with access to other data that is useful for quality improvement (e.g. NSQIP) may use these data instead, with approval from the hospital.
• For areas where we do not have service level data, divisions/departments may review hospital aggregate data and use these data to guide quality improvement, or they may use a different source of data as noted above. We do not anticipate that physicians from any division or department would be unable to participate in the program due to data unavailability.

Data availability:

• Data is currently available for all inpatient areas at St. Joseph’s, St. Michael’s and Providence, with the exception of mental health, pediatrics and intensive care units.
• Patient experience surveys for these excluded areas will begin in 2025-26 and data will be shared when a reliable sample size is available.
• Updated FY 2024-25 inpatient data along with FY 2023/24 for comparison will be shared with Chiefs by May 16, 2025.
• Patient experience data is also available for the emergency departments and many outpatient clinics. Updated FY 2024-25 outpatient data will be shared with the Chiefs by June 16, 2025.

Information on how to participate in this program for any new active physicians will be shared in June. For any questions, please contact one of the individuals listed below.

Regards,

Irfan Dhalla, VP Clinical Programs, Quality & Equity

Sam Vaillancourt, Physician Lead for Care Experience Measurement & Improvement

Cathy O’Neill, Senior Director, Care Experience, Quality & Safety