IHF Guide to submitting a complete
“Post-assessment Action Plan”
After completion of the IHF assessment, the College of Physicians and Surgeons of Ontario (the College)
receives a report from the assessor(s). Prior to the assessment report being forwarded to the IHF
Facility Review Panel, the licensee will receive a copy of the assessment report and have 14 days to
respond to the report with the opportunity to address any of the recommendations and/or provide
additional information for the IHF Review Panel’s consideration. If a written response is not received
within the 14 day timeframe, the assessment report will go to panel for disposition.
A complete Action Plan should include:
1. The action plan should individually address each recommendation made in the assessment report, in
the order they appear in the final recommendations section (usually the last page (s).
2. The proposed corrective action should answer the following questions:
• Who is taking the action?
• What action is being taken, including frequency, if applicable?
• When will actions be taken?
• Please be sure to indicate how the recommendation is going to be implemented and
how it is going to be monitored, if appropriate.
3.
All action plans are to be reviewed and SIGNED by the licensee and the Quality Advisor. By
having the licensee and the Quality Advisor review and sign the action plan, they are agreeing to
ensure that the action plan will be implemented, and any action taken, will be monitored. Any
action plan not signed off will not be considered complete.
4. If your action plan refers to any policy creations or revisions, please submit a copy of the new or
updated policy for review by the assessors. If you have been advised to create a policy and
procedure (P&P) manual and or review/update a substantial amount of your P&P manual you
must submit the entire manual for review by the assessors. Note: While it is not expected for
the facility to deliver a complete new policy and procedure manual within 14 days – the facility
can comment that they will put the manual together with a timeframe of completion. This
will then be reviewed by the assessors. A recommendation for staff to review contents of the
P&P manual requires you to submit a copy of the staff sign off sheet documenting their
completed reviews.
5. If your action plan includes updating BCLS, CME and or any other certification, equipment
purchase etc. you must submit evidence of completion, registration, or invoice etc. If there is an
intention to follow through on the recommendation in the future, a time-line and explanation
should be expressed.
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Note: If new or replacement equipment has been purchased you are also required to notify the ministry
of this information including the type of equipment and the make, model and serial number.
6. Any recommendation that requires a facility to notify or communicate reminders to
technologists/physicians should be communicated to staff in writing and acknowledged with a
sign off sheet. A copy of the memo and sign off sheet should be submitted.
7. Recommendations that suggest specific calculation or clinical practice changes should be
supported by evidence of implementation. Suitable evidence includes examination/test/results
examples MUST have had all patient identifiers removed.
Plans should be emailed or faxed (if confidential information is included) to ensure they are properly
received and help to expedite the process. This information is available below.
College IHF Program staff will work with you to answer your questions and to clarify which documents
are required to accompany your action plan. Please do not hesitate to contact us:
Telephone: 1-800-268-7096 or 416-967-2600
Tracey Marshall, Supervisor, Ext. 223
[email protected]
Nadia Mura, Assessment Coordinator, Ext. 365
[email protected]
Jennie Sun , Program Assistant, Ext. 587
[email protected]
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