FEATURE

OMA Position Paper

OMA Policy on Accountability

in the Health-Care Sector

P
hysicians in Ontario have a long-standing tradition of being accountable
— foremost to their patients, but also to the College of Physicians and
Surgeons of Ontario, to the Ministry of Health and Long-Term Care, and to
hospitals.1 They are now facing demands to demonstrate that accountability
from health consumers, from a government that is concerned with the rising
cost of health care, and through increased regulation. This is exemplified by
legislation providing for hospital service accountability agreements2 and for
agreements between the Ministry pcomm/omr/mar/08accountabil- patients may be accountable in
and the Local Health Integration ity.htm) described various aspects of health-care systems. One is issue-spe-
Networks (LHINs).3 This increased accountability that are currently rel- cific and time-limited, and the other
demand for accountability is a soci- evant to physicians, including regu- is systemic. Care contracts relate pa-
etal trend, not limited to physicians latory frameworks. It also reviewed tient behaviours relevant to a specific
or to the health-care field. Govern- some of the issues related to the condition and are time-limited.5 In
ments — federal and provincial — are measurement of performance in contrast to these quite specific care
requiring accountability from their accountability systems. Those will contracts, there are system-wide
Ministries and agencies, and expect- not be reiterated in this document. examples of patient accountability,
ing formal evaluations of their pro- There are several exceptions to such as are used in the German
grams. After years of scandal in the the accountability framework in health-care systemiv,v and West Vir-
corporate world, shareholders and Ontario. Because of the way that ginia’s Medicaid Plan.vi,vii,viii These sys-
regulators are demanding more ac- LHINs are structured legislatively, temic accountability provisions have
countability from corporations as well. physicians are outside the direct consequences for patients that raise
Accountability is the requirement authority of the LHINs and there- moral and ethical issues.6 A compre-
to answer for what you have or have fore have no accountability relation- hensive examination of the issues
not accomplished that is of signifi- ship with them. However, LHINs do and the evidence would be indicated
cance and of value.i It is a relationship have a planning and oversight func- before the issue of systemic patient
between individuals, but also a pro- tion for institutions and agencies accountability is addressed expressly.
cess that requires review of perfor- with which physicians are inter- That is beyond the purview of this
mance, including corrective actions dependent. It is therefore important document.
and consequences. ii Performance that LHINs engage physicians in In this document, the ways in
review often includes disclosure of deliberations, and that physicians which health-care systems and cor-
performance measurement data that participate in those deliberations.4 porate systems have begun to address
have been collected, aggregated, and Under the current Ontario regula- accountability are described. Often,
analyzed. tory framework, patients do not share descriptions of accountability mech-
The 2007 OMA Background Paper accountability for the behaviours anisms in the research literature do
on Physician Accountability (posted that influence their health and health not meet the formal definition of
online at: http://www.oma.org/ care. Broadly, there are two ways that accountability given above. They are

1 Ontario Medical Review •July/August 2009 Ontario Medical Review •July/August 2009 17
OMA Policy on Accountability
beginning processes that do not fit
the criteria with regard to perfor-
mance review or consequences.
Accountability principles for physi-
cians, listed at the end of this docu-
ment, are ideals (see p. 24). They are
intended to reflect how physicians
are and should be accountable, but
also how other participants in the
system are, and should be, account-
able to physicians. This duality is of
utmost importance.
The trend toward increased ac-
countability and transparency is
demonstrated in various ways, such
as evidence-based medicine, alter-
native payment mechanisms, and
strategies that originated in the cor-
porate world, but have been adopted
by the health-care system.
Evidence-Based Medicine
In recent years, there has been a shift
to recognition of the value of large,
objective data sets as the basis for
clinical decision-making. Dr. David
Sackett of McMaster University, a
pioneer in evidence-based medi-
cine, defines it as follows:
“The practice of evidence-based med-
icine means integrating individual clini-
cal expertise with the best available
external clinical evidence from system-
atic research.”7
By itself, evidence-based medi-
cine is not an accountability mecha-
nism. Only when it is combined
with incentives and review is it an
accountability tool.
The corporate world is now look-
ing to evidence-based medicine as a
management model. Business man-
agement science leaders, 8 advocat-
ing for evidence-based management
in the Harvard Business Review, sug-
gest that the theoretical argument
for evidence-based management is
ironclad — decisions made on the
basis of a preponderance of evi-
dence, particularly within one’s own
company, will be better decisions
and will help organizations thrive.ix
Evidence-based medicine can
enhance, but it cannot replace, the
clinician or diagnostician’s expertise
and experience. There is a complex
18 Ontario Medical Review •July/August 2009
dynamic that exists in the physician-
patient encounter that cannot be
reduced to following a set of pre-
scribed rules for all patients, such as
those given in practice guidelines.
Moreover, decision trees associated
with practice guidelines can affect
the physician’s cognitive processing
in ways that are not always entirely
positive. Thus, if the physician’s
mind is set on filling in the blanks in
a template, he or she may be less
likely to engage in open-ended ques-
tioning with the patient. The infor-
mation in the template becomes
more cognitively available, and the
questioning that could lead to other
information does not occur.
These decision trees may lead
physicians to use cognitive “availabil-
ity heuristics” in situations that may
be inappropriate for particular
patients. These are situations in
which people assess the probability
of an event by the ease with which
instances can be brought to mind. A
physician who faces a decision tree
will have the information in the tree
more readily available, rather than
the information that might be given
by a particular patient. Research has
shown that the availability of such
heuristics can lead to errors in deci-
sion-making. 9,x Clearly, evidence-
based medicine is not a panacea.
However, it can be useful as a tool for
physicians to help them keep abreast
of current research developments
that could be valuable to them and
their patients, to reduce uncertainty,
and to reduce practice variation.
Evidence-based clinical practice
guidelines are based on epidemiolog-
ical and statistical logic. The best
guidelines are validated by clinical
trials that are designed to determine
whether an intervention has the diag-
nostic or therapeutic benefit it claims
to have, and whether it is more effec-
tive than other interventions.xi
Provided that physicians are aware
of the potential for decision bias,
practice guidelines can enhance the
physician’s clinical and diagnostic
skills and improve patient care. For
physician specialists, they can also
improve the extent to which the cor-
rect interpretation of a procedure is
communicated to the referring physi-
cian and the patient. One physician
likens practice guidelines to a jazz
score with physicians working from a
basic chord structure and melody line,
with latitude for improvisation.xii
There is variability in the quality
of the guidelines that are available
— some are based on high-quality
evidence, but the evidence for others
is less rigorous. Evidence-based clin-
ical practice guidelines are available
online from a variety of sources, inclu-
ding the Canadian Medical Associ-
ation and the British National Health
Service. 10 Specific specialties may
have their own guidelines, such as
those produced by the American
College of Radiology, which pro-
vide, along with technical standards
and practice guidelines, appropriate-
ness criteria to assist referring physi-
cians to make the most appropriate
imaging or treatment decision.11 The
Agency for Healthcare Research and
Quality,12 instituted to improve the
American health-care system, has
contracted with 13 designated evi-
dence-based practice centres, three
of which are in Canada: the Uni-
versity of Alberta, University of
Ottawa, and McMaster University.13
Those sites also have a variety of evi-
dence-based practice guidelines.
At least some Ontario physicians
are using practice guidelines success-
fully. A survey of Ontario surgeons,
radiation oncologists and medical
oncologists indicated that this sub-
group of physicians uses Cancer
Care Ontario’s practice guidelines,
considers them useful, and, in par-
ticular, has confidence in their qual-
ity.xiii The 2007 Hospital Report: Acute
Care xiv indicates that about 38% of
Ontario hospitals are using stan-
dardized protocols for the diagnosis
and treatment of common clinical
conditions and procedures.
In Ontario, in the 2008-2009 fis-
cal year, $11.7 million was paid in
incentives by the Ministry of Health
and Long-Term Care to about 3,900
physicians who followed diabetes
management protocols, essentially
an evidence-based best practice strat-
Ontario Medical Review •July/August 2009 2
OMA Policy on Accountability
egy, for their diabetic patients.14 Over
the last several years, Ontario has
begun to use incentive payments to
direct physicians’ efforts toward par-
ticular patient populations and
improve their care; the diabetes strat-
egy is one example of this.15
Evidence-based guidelines can be
a means for physicians to be more
accountable to themselves, to their
patients, and to the profession. They
do have the potential to open the
profession to third-party account-
ability when government or private
insurers can enforce practice guide-
lines by linking them to physicians’
incomes, such as is done in pay-for-
performance models in the United
Kingdom and the United States.
One way to resolve this potential
conflict between physician autonomy
and use of clinical practice guidelines
is for the profession to take the lead in
developing evidence-based guide-
lines. In that way, they give up some
individual autonomy for science that
they as a profession endorse.xv
Ontario Initiatives
There are a variety of initiatives
underway in Ontario. Academic
physicians have led the way with
payment plans that include account-
ability mechanisms. The Ministry of
Health and Long-Term Care is pro-
viding incentives for physicians to
follow evidence-based guidelines,
and for hospitals to reduce the length
of emergency department stays.
Academic Health Science Centres
Alternate Funding Plan
The 2004 Memorandum of Agree-
ment between the OMA and the
Ministry of Health and Long-Term
Care required the establishment of an
Accountability Expert Panel to de-
velop a framework for the measure-
ment, accountability and reporting of
deliverables and a methodology for
evaluating requests for additions to
the complement of physicians at each
Academic Health Science Centre.
The Academic Health Science
Centres Alternate Funding Plan
3 Ontario Medical Review •July/August 2009
(AHSC AFP) provides for accountabil-
ity in the domains of clinical services,
academic activities, leadership, and
innovation. Participating physicians
have an appointment at a university,
have medical staff appointments at a
hospital with hospital privileges, are
members of a hospital department,
and are AFP Practice Plan members.
The governing agreements are among
the Ministry, the physician organiza-
tion, the university, the hospital, and
the Ontario Medical Association.
In the 2008 agreement, perfor-
mance measures include total OHIP
billings, patient service volumes,
number of medical students, and
number of full-time equivalents
(FTEs). After the first funding year, the
Ministry may penalize participating
physicians in any specialty group at an
AHSC if they provide less than 90%
of clinical services set out in the
accountability template.16 Thus, this
agreement includes the accountabil-
ity aspects of review of performance
for meeting volume objectives and
consequences for not meeting those
objectives. However, neither account-
ability provisions nor penalties are at
the individual physician level.
Interprofessional Care Teams
Interprofessional care is a multidisci-
plinary, team-based approach to
practice, with health-care profession-
als interacting to solve common
issues. Successful interprofessional
care provides mechanisms for ongo-
ing communication among care-
givers, optimizes participation in
clinical decision-making within and
across disciplines, and fosters respect
for the contributions of all profes-
sionals within the group.xvi
Many Ontario physicians partici-
pate in interprofessional care. Ontario
physicians have a variety of arrange-
ments — formal interprofessional
teams, groups of physicians sharing
services of other health-care provi-
ders, or more informal liaisons be-
tween physicians and community
resources. Regardless, within those
groups, clearly delineated account-
ability for various aspects of patient
care is crucial for effective functioning,
good patient care, and patient safety.
The OMA Policy on Interpro-
fessional Care addresses the issues
and specifies the necessary features
for successful interprofessional care. It
is available online (www.oma.org/
pcomm/omr/sep/07maintoc.htm).
Because of their relevance to account-
ability, several of the principles of the
interprofessional care policy are reit-
erated in the accountability principles
at the end of this document.
Ministry of Health and Long-Term
Care Emergency Department
Pay-for-Results Program
In 2008, the Ministry of Health and
Long-Term Care announced the
implementation of a new hospital
emergency department pay-for-
results program under the Ontario
Wait Time Strategy. Twenty-three
hospitals with high-volume emer-
gency rooms and lengthy ER wait
times were designated to receive a
one-time performance improvement
funding initiative intended to reduce
emergency department length-of-
stay and improve satisfaction.
Funding is dependent on reducing
wait times for higher-acuity patients,
reducing the number of patients with
wait times greater than 24 hours, and
ensuring that wait times for lower-
acuity patients do not worsen. Par-
ticipating hospitals are also required
to regularly track patient satisfaction
and monitor quality of care. The
Ministry expects to expand the pro-
gram in 2009-2010.xvii
Accountability Provisions in
Other Jurisdictions
Programs in other provinces and
other countries have addressed
accountability in various ways —
through policy documents, legisla-
tion, and demonstration projects.
Quebec Public Health Act
Quebec’s Public Health Act 17 is in-
tended to ensure that physicians are
accountable to the Quebec Ministry
Ontario Medical Review •July/August 2009 19
OMA Policy on Accountability
of Health and Social Services. Under
the Act, physicians are required to
report to the public health authori-
ties unusual clinical manifestations
due to vaccination, and to report
intoxications, infections, and dis-
eases that are on a regulated list.
Physicians must treat individuals
with contagious diseases or infec-
tions, or direct them to treatment;
physicians are also required to
report to authorities those individu-
als suffering from such diseases or
infections who refuse treatment or
examination. To ensure account-
ability under the Act, physicians fail-
ing to make such reports or notices
are subject to a fine.
Quebec has recently appointed a
Health and Welfare Commissioner,
who is responsible for assessing the
results achieved by the health and
social services system, and for report-
ing to the public about the govern-
ment’s efforts to address major
issues.18 Under the Public Health Act,
the Ministry may require physicians
to provide aggregate data to assist
with its ongoing surveillance of the
health status of the population.
Alberta Bone and Joint Health
Institute
The Alberta Bone and Joint Health
Institute has built a model of carexviii
based on the principles of evidence-
based prevention, diagnosis and treat-
ment, guaranteed access, continuous
evaluation, and patient-centred care.
The Institute considers optimizing
access, quality, and cost to be key ac-
countability dimensions. Patients are
assigned case managers at intake.
There are standardized care paths and
standards of access and quality. The
system has almost immediate feed-
back of access, quality, and cost data.
In recognition of the important role of
patients to their own health, the Insti-
tute requires patients to sign a “care con-
tract” to participate in their own care.
Australian Reforms
Historically, the Australian Health
Care Agreements (AHCAs) were
20 Ontario Medical Review •July/August 2009
purchasing agreements between the
Commonwealth and the states with
regard to free public treatment in
hospitals. In its recent report,xix the
Australian National Health and
Hospitals Reform Commission sug-
gests a new division of accountabil-
ity between the federal government
and the states. The federal govern-
ment would be accountable for pri-
mary care, aged care, prevention,
and the health of Indigenous peo-
ples. The states would be account-
able for public hospitals, mental
health, maternal and child health
services, and public health services.
Performance measures would cross
the entire health system, including
general practitioners, as well as hos-
pitals and other health services.
The Australian system is quite
different from the Canadian one,
however, in that a large portion of
Australians have both public and
private health care. All Australians
pay a 1.5% tax on income for health
care, but about 40% take out private
health coverage, which entitles them
to a specialist of their choice and
treatment in a private hospital.xx
Pay-for-Performance Programs
Other counties, most notably the
United States and the United King-
dom, have moved extensively into
pay-for-performance systems as an
alternative to fee-for-service. Pay-for-
performance systems assume that by
rewarding physicians for quality of
care, rather than paying for the num-
ber of services provided, patient
health and the health-care system
can be improved. Quality of care is
measured either by outcome or
process measures. The Ontario dia-
betes incentive is an example of a
process measure. Outcome measures
are related more clearly to patient
health status, but are also more diffi-
cult to measure, particularly in the
prevention arena.
The best systems will probably use
process measures that are demon-
strably tied to improved outcomes.
Pay-for-performance systems require
the ability to collect and aggregate
data, usually accomplished through
information technology systems that
include electronic medical records.
As of 2006, more than half of all
American state Medicaid programs
were operating one or more pay-for-
performance programs. Most Ameri-
can Medicaid pay-for-performance
programs use standardized clinical
performance measures related to pre-
ventive and primary care and to treat-
ment and management of chronic
diseases. Measures are maintained
centrally by the National Committee
for Quality Assurance. They are
directed toward such health issues as
asthma, hypertension, cancer, cardio-
vascular disease, childhood immu-
nizations, chronic obstructive
pulmonary disease, depression, dia-
betes, osteoporosis, and smoking.xxi
Some programs use structural mea-
sures related to a specific status or
activity, such as adoption of informa-
tion technology, wait times, or hours
of operation.
Many of the initiatives in the Amer-
ican Medicaid programs have been
remarkably successful in improving
care. Probably the most notable is the
change in the percentage of patients
who had suffered a heart attack and
were prescribed beta-blockers,xxii an
increase from 62% in 1996 to 96% in
2005. There are some exceptions,
however. The quality of care for
patients suffering from mental illness
has not improved since 1999, as mea-
sured by follow-up after hospitaliza-
tion. Patients with some complex
illnesses or comorbidities present
challenges to physicians treating
them, and may not be amenable to
standardized solutions.
Corporate Strategies Adopted
by the Health-Care System
In the corporate world, performance
review has typically been assessed in
terms of number of sales or amount
of profit. Reward to those who meet
their performance accountability
requirements is characterized by in-
creased salaries and stock options, as
well as other perquisites. These are
valuable and motivating incentives
Ontario Medical Review •July/August 2009 4
OMA Policy on Accountability
in situations where employee perfor-
mance increases profitability. How-
ever, those performance measures
and rewards do not represent an ap-
propriate means of measuring or
rewarding physician performance.
Nevertheless, some aspects of cor-
porate practice do transfer to parts of
the health-care system. A few Ameri-
can hospitals are attempting to
address safety issues using Toyota’s
production system, called kaizen,
which focuses on continuous use of
problem-solving techniques to
improve processes and increase
safety. By using the Toyota model,
the health-care system is looking to
the corporate world for solutions.
In the Toyota system, there are
detailed specifications of how work is
to be done before it is performed; that
is coupled with testing work as it is
done. The specification is somewhat
analogous to a temporary best prac-
tice until a new problem is discov-
ered, at which time the problem is
analyzed experimentally and re-
solved.xxiii The focus is on continuous
learning, improvement, and innova-
tion for all staff — managers and line
workers alike — using the scientific
method.xxiv
In some American hospitals, im-
plementation of this system to im-
prove processing has lead to
reduction in infection rates and med-
ication errors. The idea is to empower
staff to examine and change current
processes in a systematic way and to
continue to use those learned strate-
gies to improve processes. Toyota’s
production system engages workers
to become more accountable for the
efficiency of production; it is one of
the main factors that has led Toyota
to be such a profitable corporation.
A similar focus on examination of
processes has been used with suc-
cess in some Ontario hospitals with
coaching teams organized by the
Ministry of Health and Long-Term
Care. The goal of the coaching teams
is to help hospitals develop their
own problem-solving capacity and,
like the Toyota system, learn to im-
prove their own systems and pro-
cesses continuously.xxv For example,
5 Ontario Medical Review •July/August 2009
at The Ottawa Hospital, palliative
care components will be function-
ally integrated into the critical care
units. At Norfolk General Hospital,
recommendations will enable
improved scheduling and use of
resources in the OR and in ambula-
tory care. xxvi These are ways to
attempt to improve the quality of
services — in the corporate world
and in health care. They increase
individual responsibility for im-
proved processes.
When improved processes are
tied to consequences, they represent
accountability mechanisms. The
Toyota example is a process model
that is probably most applicable to
small units in the health-care sys-
tem, such as exemplified by the hos-
pital units engaged by Ministry
coaching teams.
Public Reporting and
Physician Profiling
Many jurisdictions have introduced
public reporting of health quality
measures as a means of demonstrat-
ing public accountability and trans-
parency, improving the quality of
health care, and containing health-
care costs. Physician profiles are also
intended as a means of increasing
accountability and improving qual-
ity, often through physician self-
management of change. They may
be publicly reported. Although
physician profiling and public
reporting has increased over the past
couple of decades, particularly with
American health-care plans, assess-
ments of their validity and useful-
ness suggest caution.
Public Reporting
Public reporting of data on clinical
performance is fairly common in
the United States, but it is relatively
new in Ontario. There are conflict-
ing reports about its impact on clini-
cal care. For illustrative purposes, a
few examples of public reporting are
provided below. Most are at the sys-
tem level, rather than at the individ-
ual level or group physician level.
Ontario Hospital Report Research
Collaborative
In Ontario, the Hospital Report Re-
search Collaborative (HRRC)19 has
published reports on the perfor-
mance of Ontario hospitals for about
10 years.20 The HRRC uses a balanced
scorecard of indicators for measures
of hospital performance. Individual
reports cover acute care, emergency
department care, complex continuing
care, rehabilitation and mental
health.
The HRRC is funded by the On-
tario Hospital Association and the
Ontario Ministry of Health and Long-
Term Care. The reports indicate that
the primary audience is intended to
be hospital boards of directors, senior
managers, and Local Health Inte-
gration Networks, and that the infor-
mation is intended for strategic
planning and priority setting.
The information seems to be use-
ful; for example, the 2007 acute care
report indicates that there is improve-
ment from 2006 to 2007 in the ex-
istence of formal procedures for
removing patients from wait lists and
in measures of patient safety.
College of Physicians and Surgeons
of Ontario
The College of Physicians and Sur-
geons of Ontario publishes on its
website summaries of the decisions
of the Discipline Committee, by
month and year, along with the
names of the physicians and sum-
maries of the decisions.21
Health Quality Councils
Ontario, Saskatchewan, Alberta, and
New Brunswick have legislated health
quality councils that report annually
to government on the quality and
performance of their health systems.
Reports are available online.22
California Pay-for-Performance System
In California, public reporting of
physician group performance is a key
part of the pay-for-performance pro-
gram. xxvii Each medical group gets a
summary rating for meeting national
standards of care. The rating is based
on the average score across 13 mea-
Ontario Medical Review •July/August 2009 21
OMA Policy on Accountability
sures.23 These reports are available on
the Internet 24 by county, physician
group within a given county, and by
measure for each group. They are also
available in print in public libraries
and major drug store chains. Ratings
are provided on a four-point scale. An
individual can look up results for any
physician group on any of the mea-
sures. This public reporting provides
the opportunity for patients to make
their provider decisions based on
information provided in the online
assessment.
Wisconsin Collaborative for Health-Care
Quality
This collaborative, established in
2003, is physician-led. In 2007, it
included 28 physician groups, hos-
pitals, and health plans that re-
ported data for more than 50% of
Wisconsin’s physicians. Its goal is to
improve the quality and cost-effec-
tiveness of health care. It reports
comparative measures of perfor-
mance in ambulatory and hospital
settings using data submitted volun-
tarily by provider organizations. As
well as achieving public reporting of
primary care sites, it has a model for
translating evidence-based medicine
into community practice. A variety
of aggregate data are provided on-
line25 by topic at the physician group,
hospital, or health-care plan level.
Assessments of Public Reporting
A recent survey of 18 experts in the
U.S. health-care system about public
reporting of health-care performance
indicated concerns over measure-
ment and interpretation, including
data quality, validity, reliability,
accuracy, and risk adjustment.
Respondents also suggested the need
to involve stakeholders in the design
of indicators.xxviii
A Canadian review of the litera-
ture on performance reportsxxix indi-
cates that they have little effect on
consumer knowledge, attitudes or
behaviour, but that consumers who
do use the reports to make change
find the data useful.
The research on the effects on
group providers, such as hospitals,
22 Ontario Medical Review •July/August 2009
managed care plans, hospital trusts,
and regions, is larger than that on
health-care providers, and the results
are more positive. Nevertheless, the
interpretation of the meaning of the
differences in terms of patient out-
comes is controversial.26
One effect of public reporting
may be to focus public attention and
government funds on particular
areas. When this occurs, the result
may be neglect in other areas, possi-
bly of equal importance, and in-
equities in the system.
Physician Profiling
Physician profiles, also called physi-
cian report cards or score cards, con-
tain evaluative information about
the physician’s clinical performance.
Evaluative information in the pro-
file may be restricted to the physi-
cian, shared with regulatory bodies,
or made public.
The collection and reporting of
these data varies widely in sophisti-
cation — some are comprehensive,
controlled evaluations; others per-
mit the public to post any evalua-
tion. Public reporting of individual
physician data has the potential to
result in refusal of care to complex
patients who may lower scores. The
evidence concerning this practice is
inconclusive.
Council of Academic Hospitals of Ontario
360-Degree Physician Performance Review
The Council of Academic Hospitals
of Ontario (CAHO) has recently
released its plan for a 360-degree
physician performance review. It is
modelled after the Alberta Physician
Achievement Review process de-
scribed below.
The review process would apply to
physicians in Ontario’s 25 academic
hospitals. Like the Alberta program,
it would provide for review by
patients, peers, consultants, and
other clinicians. The plan suggests
linking the 360-degree performance
evaluation with quantitative indica-
tors, such as length of stay, infection
rate, and mortality. It recommends
that results be shared with the physi-
cian and the department chief, that
the assessments be mandatory, and
that all physicians be assessed on a
rotational basis every three years to
five years. It also recommends that all
information collected be confidential
between the physician and the chief,
and not available to hospital admin-
istrators or boards of directors.xxx
Alberta Physician Achievement Review
The Alberta Physician Achievement
Review (PAR) process was man-
dated by law in 1999. 27 It provides
for review by patients, medical col-
leagues, co-workers, and by physi-
cians themselves, with each group
assessing on some dimensions.
Physicians are assessed by their
medical colleagues on clinical com-
petency, psychosocial management
of patients, patient interaction, and
professional self-management. They
are assessed by co-workers on patient
interaction, co-worker collegiality,
and co-worker communication. Pa-
tients assess on patient interaction,
telephone communication, patient
information, personal communica-
tion, office staff, physical office, and
appointments. Physicians assess
themselves on all attributes of all
dimensions.
All Alberta physicians are required
to have a review every five years, with
about 1,000 physicians reviewed per
year. Each physician asks eight physi-
cian colleagues, eight non-physician
co-workers, and 25 patients to com-
plete a questionnaire. Data are ana-
lyzed by an independent body with
results provided to physicians in a
manner that they can compare their
self-ratings with those of patients,
colleagues, co-workers, and with
provincial norms. Those scoring in
the top and bottom 10% are flagged
for attention and review by the
College of Physicians and Surgeons
of Alberta.28 However, PAR informa-
tion is strictly for educational pur-
poses and cannot be used in any
advertising, disciplinary action, or
legal process.xxxi The PAR website pro-
vides a variety of sources for practice
improvement and education for
Alberta physicians.29
Ontario Medical Review •July/August 2009 6
OMA Policy on Accountability
RateMD.com
RateMD.com is an international
online forum that permits users to
rate their physicians on a five-point
scale on the dimensions of staff,
punctuality, helpfulness, and knowl-
edge.30 Scores are summed and physi-
cians rated overall as good, average,
or poor. Individual scores, com-
ments, and summary scores are avail-
able to the public and to physicians.
The anonymous information pre-
sented at RateMD is unsubstantiated
and open to abuse by disgruntled
patients or unknown others. Approx-
imately 16,000 Ontario physicians
have been rated.
New York State Cardiac Mortality Rates
In New York State, cardiac bypass
mortality rates are published by hos-
pital and by surgeon. Whether publi-
cation results in physicians refusing
high-risk patients has been ques-
tioned. One survey of physicians
indicated that physicians thought
that public reporting does result in
high-risk patients being refused ser-
vice, specifically because of the
State’s public reporting require-
ments. However, another report that
analyzed the data showed no evi-
dence of systematic bias against
operating on high-risk patients.xxxiii
Massachusetts Online Physician Profiles
Massachusetts physician profiles 31
provide access to information about
the education, training, and experi-
ence of all physicians. That includes
their publications, malpractice claims
paid, hospital discipline, criminal
convictions, and disciplinary actions.
However, there is no clinical evalua-
tive information provided.
Episode-Based Physician Profiling
The newest approach to physician
profiling is episode-based. An epi-
sode of care refers to a period during
which a disease process is present
and is being managed, diagnosed
and treated by health-care providers.
To assess the quality of physician
performance, the method uses
claims databases to extract informa-
tion related to the degree of compli-
7 Ontario Medical Review •July/August 2009
ance with various clinical guide-
lines. It is being used in the U.S. in
national and regional health plans.
Measures of quality of performance
are developed by using claims data-
bases to extract information about
the degree of compliance with vari-
ous clinical guidelines. Performance
can be assessed in terms of relative
compliance rate or as satisfying an
absolute compliance rate standard.
Similarly, cost-efficiency measures
can be calculated and physicians
compared, within specialty, on rela-
tive cost-efficiency performance.xxxiv
Assessment of Physician Profiles
The research on the effects of perfor-
mance reports on health-care pro-
viders, mainly physicians, shows
mixed results, with many papers cit-
ing the same cardiac mortality re-
porting and analyses described
above for New York State.
A small survey in Ottawa indi-
cated that family physicians were
receptive to performance assessment
feedback and found it useful, but
had reservations about such infor-
mation being shared with patients.
When asked to rank their account-
ability to patients, professional bod-
ies, peers, funding bodies, and
others (self, specialists, family and
friends), patients were ranked first
by all respondents.xxxv
A 1998 American assessment of
data use by primary care physicians,
pediatricians, and internists, from
profiles for improving patient care,
indicated that about one-quarter
found profiles useful or very useful,
and another 40% found them mod-
erately useful. Over half used them
to change patient care practices
often, always, or sometimes. But,
almost half never, or rarely, used
them to change patient care.xxxvi
Assessment of the episode-based
method of physician performance
measurement indicates that, because
of the variation in detail and com-
prehensiveness of claims data, it
offers opportunities for misidentifi-
cation of low-performing and high-
performing physicians. Moreover,
clinical criteria are available for a rel-
atively small set of conditions that
are delivered by only a few special-
ties.xxxvii
Risk Adjustment and Risk
Sharing
All reimbursement systems have
financial incentives and risk. How-
ever, compared to American models,
where much of the health-care sys-
tem is administered on a for-profit
basis, Ontario physicians assume rel-
atively little financial risk. Never-
theless, in some models, there is
modest risk. In Ontario, physicians
in capitated models, such as Family
Health Networks (FHNs) and Family
Health Organizations (FHOs), paid
on a per-patient basis, are subject to
negation of their access bonus 32 by
the amount of outside use. Thus, if an
enrolled patient sees another phy-
sician, who then charges OHIP for
services, this reduces the original
physician’s total access bonus by the
amount of outside use.
Risk Adjustment
Risk adjustment is the use of infor-
mation to calculate the expected
annual health-care costs of individu-
als and to subsidize those costs.
There are methods of adjusting capi-
tated models for risk: reinsurance,
and various risk adjustment models,
are two primary methods.
Reinsurance is individual stop-
loss coverage that provides that the
physician is responsible for the
health-care costs of an individual
only up to a certain dollar threshold
over a given time. It is used in the
U.S. to protect physicians paid by
capitation, especially those in small
groups, from losses due to catastro-
phic illnesses or events.
Risk adjustment models include
demographic models based on char-
acteristics such as age and sex, func-
tional health models that measure
ability to perform daily living tasks
or that assess previous health-care
spending, and clinical indicator
models that use diagnostic informa-
tion from claims or encounter data.
Ontario Medical Review •July/August 2009 23
OMA Policy on Accountability
Another strategy to reduce physi-
cian financial risk is to use what are
called “carve-outs.” With this method,
services, conditions or populations
are carved out of the capitation pay-
ment and reimbursed on a fee-for-ser-
vice basis. xxxviii “Case rates” for
procedures that have predictable
lengths of treatment, or “episode of
care rates” for services for a single
episode for a patient, are both types
of carve-outs.
In Ontario, capitated payment
models use both risk adjustment
and carve-outs. Rates for physicians
are risk adjusted for patient age and
sex; extra fees, payments, incentives
and bonuses are carved out for par-
ticular patient populations and for
specific health-care services. Risk
adjustment is also used in Israel,
Europe and the United States.
The Israeli and European health-
care systems are quite different from
those in Canada or the U.S. In the
Israeli health-care system, for exam-
ple, four non-profit sickness funds
contract with providers to provide
medical care; citizens must choose
from one of the four funds. Risk
adjustment is based on age, gender,
and region. Five “severe diseases”
are carved out and paid separately.
Health insurance is mandatory for
all citizens, and the funds are obliged
to accept all applicants.xxxix
Similar systems that have a com-
petitive market for sickness funds exist
in Belgium, Germany, the Neth-
erlands, and Switzerland. In these
countries, all citizens have a guaran-
teed choice of sickness funds that
either provide them with medical care
or purchase care for them, although
the number of funds in a country
varies from four in Israel to 275 in
Germany. All countries have methods
of risk adjustment, including age,
gender, urbanization, disability,
income, historical costs, social status,
family composition, and chronic ill-
ness. The addition of some of the
health-based risk adjusters after the
plans had been in existence for a year
or two im-proved the systems. In
some countries, special risk-sharing
arrangements are made for outliers.xi,xli
24 Ontario Medical Review •July/August 2009
Risk Sharing
Some American risk-sharing models
include not only primary care and
specialist physician services, but also
inpatient hospital services and phar-
maceuticals. Generally, as the scope
of provided services increases, finan-
cial risk increases.
In the U.S., some capitated systems
have failed because of an insufficient
number of patients and/or an insuffi-
cient number of providers to share
the risk.xlii If risk is distributed across a
large patient population, the effect of
a few extremely high-cost cases is
ameliorated. In Ontario, physicians
in capitated models have the option
of having capitation payments made
to the individual physicians or to the
group.
The American trend appears to be
away from risk-sharing models, or to
limitation of their scope, although
Medicaid-managed care plans may
be an exception.xliii Poor utilization
management, rising medical costs,
inadequate capitation increases, and
financial failures among medical
groups have led American physicians
and hospitals to rebel against the
amount of risk they were assuming.xliv,xlv
Many American models have
structural arrangements that include
four or five layers of contracts from
health maintenance organizations
(HMOs) through physician-hospital
organizations (PHOs), through indi-
vidual practice association (IPAs) via
a medical group to the physician, so
it is difficult to determine how much
risk is assumed by the individual
physician.xlvi Moreover, U.S. models
are not directly comparable to
Ontario models as payments origi-
nate with for-profit organizations,
and the scope of services is greater.
Summary
The past few years have shown in-
creased demand for accountability
and transparency in health care, in
other public sectors, and in the cor-
porate world. In health care, these
demands are directed toward two
goals: improving the quality of
health care and reducing its cost.
A common response to these de-
mands has been the use of evidence-
based medicine. In Ontario, this is
linked to incentives for particular
diseases or populations which, of
themselves, are not accountability
mechanisms. In the U.K. and many
American systems, evidence-based
medicine is used as the basis for pay-
for-performance models of care.
Physician profiles are another
means of attempting to increase the
quality of health care, whether for the
sole use of the physician, or as public
information. Efforts to make systems
transparent as well as accountable are
shown by public reporting of health-
care quality at the provincial, group
practice, or individual physician level.
Rather than using incentives to
improve quality, some governments
have legislated changes designed to
increase the accountability of phy-
sicians. Alberta’s Physician Achieve-
ment Review program, and Quebec’s
public health services legislation, are
examples.
Regardless of whether it is within
pay-for-performance models, there is
increased emphasis on measuring
the performance of physicians. This
is shown in the Ontario Academic
Health Science Centres Alternate
Funding Plan, the CAHO 360-Degree
Physician Performance Review, the
proposed Australian reforms, and in
the Wisconsin Collaborative.
For Ontario physicians, account-
ability must be a reciprocal process
between them and their patients, the
College of Physicians and Surgeons
of Ontario, the Ministry of Health
and Long-Term Care, and hospitals.33
Physicians cannot be held account-
able for achieving specified outcomes
or following particular clinical guide-
lines if the necessary resources are
not available to support them.
The Ontario Medical Association’s
principles of accountability for
physicians and their partners in the
health-care system are stated below.
Physician–Patient Accountability
Principles
The OMA believes that optimal pa-
Ontario Medical Review •July/August 2009 8
OMA Policy on Accountability
tient care is achieved when accoun-
tability for health-care outcomes is
shared between physicians and their
patients. This is most readily accom-
plished when their relationship is char-
acterized by mutual respect and trust.
In the best circumstances, physi-
cians enable patients to join them in
a decision process that considers
potential risks. Physicians are legally
bound to obtain consent from pa-
tients or their agents for treatment.
Patients or their agents are entitled to
refuse treatment.34 Physicians are eth-
ically and legally bound to adhere to
the prevailing standard of care.35
Physicians are legally bound to
report to the medical officer of health
if they are of the opinion that a
patient has a reportable disease.36
Patients are entitled to be informed
of all aspects of their health care. This
includes the right of a patient to dis-
closure of harm that may have oc-
curred to him or her in the course of
receiving health care.37
Physicians are required to take
steps that are reasonable in the cir-
cumstances to ensure that patients’
personal health information is pro-
tected against theft, loss, and unau-
thorized use or disclosure.38
To improve patient care, the OMA
encourages physicians to participate
in the development of clinical prac-
tice guidelines that are evidence-
based. Physicians may choose to use
clinical practice guidelines as a tool to
supplement their clinical judgment
and enhance their clinical skills.
Physician–Interprofessional Care
Team Members Accountability
Principles
The principles cited below are taken
from the OMA Policy on Interpro-
fessional Care. Because of the im-
portance of clearly delineated
accountability for effective team
functioning, patient care and patient
safety in interprofessional team
models, they are reiterated here.
In health-care teams, a formal
process for conflict resolution should
be in place so that issues regarding
scopes of practice, roles, and patient
9 Ontario Medical Review •July/August 2009
safety can be addressed in a timely
fashion.
The OMA believes that the phy-
sician, having greater breadth of
training and larger scope of practice,
should be the clinical lead in inter-
professional teams.
Physician–College of Physicians
and Surgeons Accountability
Principles
Each physician is accountable to the
College of Physicians and Surgeons
of Ontario for his or her standards of
practice, standards of professional
ethics, standards of knowledge and
skill, conduct, and continuing med-
ical education.39
The College regulates its mem-
bers in accordance with the law, and
develops, establishes and maintains
standards of qualification, standards
of practice, standards of professional
ethics, standards of knowledge and
skill, and programs to promote con-
tinuing competence.40 As the College
is the regulator for the profession, it
should exercise its authority in a
responsible manner.
Physician–Ministry of Health and
Long-Term Care Accountability
Principles
As a steward of public funds, the
Ministry of Health and Long-Term
Care is accountable to the public for
funding decisions, including pay-
ments to physicians for their ser-
vices. The OMA is mindful of this
responsibility.
In accordance with the CMA
Code of Ethics41, physicians should
use health-care resources prudently.
Physicians must retain autonomy
in medical decision-making. Neither
the Ministry nor any other body
may usurp this authority.
Physicians who receive incentive
payments for meeting set goals for
specific patient populations or ser-
vices are accountable to the Ministry
to demonstrate that these services
have been provided.
Physicians who participate in
alternative payment plans, includ-
ing pay-for-performance plans, are
accountable to the Ministry for the
accountability provisions in those
plans, including agreed-upon mon-
etary consequences if those provi-
sions are not met.42
Physician–Hospital Accountability
Principles
The OMA believes that optimal
patient care is achieved in hospitals
when physicians and hospital ad-
ministrators strive toward the com-
mon goals of optimal patient care
and safety. Active physician partic-
ipation in the decision-making
processes of the hospital will facilitate
the achievement of these goals.
Physicians have an ethical re-
sponsibility to their hospital patients
to advocate for hospital resources to
meet their health-care needs.
Issues around resource availabil-
ity and service delivery levels are
linked integrally. Hospital decisions
to reduce, restrict, or remove funding
or other resources can be expected to
result in a change in physician ser-
vice levels.
Hospitals are responsible for pro-
viding physicians with privileges
with the resources necessary for them
to treat patients effectively and in a
timely manner according to the privi-
leges granted. This includes such
resources as professional and support
staff, operating room time, on-call
scheduling, equipment, bed space,
anesthesia services, and outreach ser-
vices. Further, hospitals are responsi-
ble for making changes in resource
availability in discussion with the
medical staff; such decisions must
not be imposed unilaterally.
As the decisions made by physi-
cians impact the financial resources
of the hospital, physicians should
consider the impact of their decisions
on hospital resources, although their
primary duty and responsibility lie
with the patient.
Physicians are accountable to the
hospital’s board of trustees through
the medical advisory committee for
the quality of the professional services
they provide within the hospital.
Ontario Medical Review •July/August 2009 25
OMA Policy on Accountability
Physicians and the hospitals in
which they serve their patients may
have individualized agreements that
specify the services that physicians
will perform, and the resources that
hospitals will provide to them.
Because of the interdependence of
some specialists, such as surgeons
and anesthetists, some agreements
may have contingencies that pro-
vide for exceptions due to the condi-
tions of another specialist.
Permission and Citation
The contents of this publication may
be reproduced in whole or in part
provided the intended use is for non-
commercial purposes and full ack-
nowledgment is given to the Ontario
Medical Association.
Ontario Medical Association. OMA
Policy on Accountability in the
Health-Care Sector. Ont Med Rev
2009 July/Aug: 17-29.
ISBN: 0919047726
© Ontario Medical Association, 2009
Author
This paper was prepared by Aura
Hanna, PhD, a senior policy analyst in
the OMA Health Policy Department.
Footnotes
1. The ways in which physicians
are currently accountable was
detailed in an OMA Board back-
ground paper, published in the
March 2008 Ontario Medical
Review, and available online at
https://www.oma.org/pcomm/
omr/mar/08maintoc.htm
(Accessed: 2008 April 14).
2. Commitment to the Future of Medi-
care Act, 2004, S.O.2004, c. 5.
3. Local Health System Integration
Act, S.O. 2006, c. 4, s. 18. The
accountability agreements are
posted online at http://www.
health.gov.on.ca/transforma-
tion/lhin/lhin_aa.html.
4. One of the goals of the LHIN
Collaborative, announced recent-
ly, is to engage the health service
provider community to ensure
collaborative and successful inte-
26 Ontario Medical Review •July/August 2009
gration (Ministry of Health and
Long-Term Care, Strategic Ad-
visory Committee and LHIN
Collaborative, Memorandum
from Ron Sapsford, Deputy Min-
ister, and Bill MacLeod, LHINs,
2009, Feb 24.
5. The Alberta Bone and Joint
Health Institute has a care con-
tract for patients undergoing
joint replacement (Frank C, Dick
D, Smith D, Wasylak T, Gooch K
& Zernicke R. The Alberta Bone
and Joint Health Institute: creat-
ing sustainable accountability
through collaboration, relevant
measurement and timely feed-
back. Healthcare Papers. 2006;7
(1):34-9). Similarly, several pain
clinics in California have trilat-
eral opioid contracts between
the specialist, the patient, and
the patient’s primary care physi-
cian (Fishman S, Mahajan G,
Jung SW, & Wilsey, B. The trilat-
eral opioid contract: bridging the
pain clinic and the primary care
physician through the opioid
contract. Journal of Pain and
Symptom Management; 24(3):
335-342. Available from http://
download. journals.elsevier-
health.com/pdfs/journals/0885-
3924/PIIS0885392402004864.
pdf. Accessed: 2009 Mar 24.)
6. For example, in West Virginia,
pediatric patients may have lower
levels of drug entitlements be-
cause of the behaviours of their
parents.
7. Sackett D, Rosenberg W, Gray
J, Haynes R, & Richardson S
(1999). Evidence-based medi-
cine: what it is and what it isn’t.
British Medical Journal, 312, 71-
72. Online at www.bmj.com/
cgi/content/full/312/7023/71
(Accessed: 2008 Mar 4).
8. The authors of this article are on
faculty at Stanford University,
Pfeffer with the Graduate School
of Business, and Sutton with the
Engineering School. Their book
on evidence-based management
has been discussed and debated
in the management literature.
Although there are critics of the
concept, there seems to be a
consensus that evidence-based
management makes for better
decisions.
9. Psychologists Daniel Kahneman
and Amos Tversky published
extensively on heuristics and
biases in decision-making. Kah-
neman won the Nobel Prize in
economics in 2002, partly for this
work.
10. CMA guidelines are at http://
mdm.ca/cpgsnew/cpgs/index.asp.
British guidelines are online at
www.nice.org.uk/. (Both accessed:
2008 Mar 12).
11. Online at www.acr.org/Second-
aryMainMenuCategories/qual-
ity_safety.aspx. (Accessed: 2009
Mar 9)
12. Online at www.ahrq.gov/(Acces-
sed: 2009 Mar 9).
13. Evidence-based practice informa-
tion is online at http://hiru.
mcmaster.ca/epc/projects.asp
(McMaster); www.uo-epc.org/
(University of Ottawa); www.
epc.ualberta.ca/(University of
Alberta) (All accessed: 2009 Mar 9).
14. OMA Economics Department.
Data are for the third year the
incentive was available.
15. This is not pay-for-performance;
in pay-for-performance models,
review is required and incentives
are contingent on performance.
In Ontario, physicians are paid
for participation.
16. Prior to funds being withheld,
the Ministry of Health and Long-
Term Care will meet with the
governance organization to
explore potential extenuating
circumstances.
17. Quebec. Public Health Act, R.S.Q.
2001, Chap.S-2.2. Online at
www2.publicationsduquebec.go
uv.qc.ca/dynamicSearch/telechar
ge.php?type=2&file=/S_2_2/S2_2
_A.html.
18. Quebec. An Act Respecting the
Health and Welfare Commis-
sioner, R.S.Q., C-32.1.1. Online
at: www2.publicationsduque-
bec.gouv.qc.ca/dynamicSearch/
telecharge.php?type=2&file=/C_
32_1_1/C32_1_1_A.html.
Ontario Medical Review •July/August 2009 10
OMA Policy on Accountability
19. The Hospital Report Research
Collaborative was superseded in
2008 by the Health System Per-
formance Research Network.
20. These are available online at
www.hospitalreport.ca/.
21. Online at www.cpso.on.ca/
whatsnew/news/default.aspx?id
=1444.
22. The Ontario Health Quality
Council reports are online at
www.ohqc.ca/en/mandate.php,
Alberta’s are at www.hqca.ca/
index.php?id=%2097, Saskatche-
wan’s are at www.hqc. sk.ca/por-
tal.jsp?LFqKTVQ7W8BD+4vt8v
meKjBIzBf0QfLQkUwK4QBZaJv
0Z63bjKY3KIzOVcA+lmY4 (All
accessed: 2008 Sept 10). Being
new, New Brunswick’s health
council has not yet reported. Infor-
mation is available at www.
gnb.ca/0051/promos/news/
health_council/health_council-e.
pdf. Accessed: 2008 Nov 18.
23. These are: asthma medicine,
breast and cervical cancer screen-
ing, child immunizations, chla-
mydia screening, testing and
controlling blood sugar and cho-
lesterol for diabetes patients,
testing kidney function for dia-
betes patients, testing and con-
trolling cholesterol, testing
children with upper respiratory
infections. Online at www.opa.
ca.gov/report_card/medical-
groupabout.aspx (Accessed:
2008 Aug 14).
24. Available online at http://www.
opa.ca.gov/report%5Fcard/.
25. Online at www.wchq.org/ report-
ing/(Accessed: 2008 Sept 10).
26. See Lindenauer P, Remus D,
Roman S, Rothberg M, Benjamin
E, Ma A, & Bratzler D (2007).
Public reporting and pay for per-
formance in hospital quality
improvement. New England J. of
Medicine, 356(5), 486-496 and
responses to that article by
Mullen & Bradley, Mansi, &
Schumacher (all NEJM, 356(5),
pp 1783).
27. Alberta Medical Profession Act,
R.S.A. 1980, Chap M-11.
28. Information about the Physician
11 Ontario Medical Review •July/August 2009
Achievement Review program is
available on the website of the
College of Physicians and Sur-
geons of Alberta at www.cpsa.
ab.ca/Services/PARprogram.aspx
(Accessed: 2008 Sept 4).
29. Online at http://www.par-pro-
gram.org/PAR-andEducation.
htm (Accessed: 2009 Mar 9).
30. Online at www.ratemds.com
(Accessed: 2008 Sept 4).
31.Online at http://profiles.mass
medboard.org/MA-Physician-
Profile-Find-Doctor.asp
(Accessed: 2008 Sept 9).
32. For physicians in Family Health
Networks, the access bonus is an
additional 20.65% over the capita-
tion payment, and for physicians
in Family Health Organizations,
it is 18.50%.
33. A background paper on physi-
cian accountability is available
in the March 2008 Ontario Medi-
cal Review, and available online
at https://www.oma.org/ pcomm/
omr/mar/08maintoc.htm
(Accessed: 2008 Apr 14).
34. Health Care Consent Act, S.O.
1996, Chap.2, Sch. A.
35. The 2004 Code of Ethics of the
Canadian Medical Association
states that the fundamental re-
sponsibility of a physician is,
“Consider first the well-being of
the patient” (Canadian Medical
Association. CMA Code of Ethics.
2004. Ottawa: Canadian Medical
Association). Available online at
http://www.cma.ca/index.cfm/
ci_id/2419/la_id/1.htm). The
regulations under the Medicine
Act also require that physicians
“maintain the standard of practice
of the profession” and that they
not practice in a “disgraceful, dis-
honourable, unprofessional” or
“unbecoming” manner. (Medicine
Act, R.R.O. 856/93, s.1 ss.1 (2, 33,
34).
36. Health Protection and Promotion
Act, R.S.O. 1990, c.H.7, s.25.
37. As specified by the College of
Physicians and Surgeons, physi-
cians are obliged to inform pa-
tients of all aspects of their health
care, including “the right of a
patient to disclosure of harm that
may have occurred to him or her
in the course of receiving health
care” (College of Physicians and
Surgeons of Ontario, 2003).
Disclosure of harm. Toronto:
CPSO. Available online at www.
cpso.on.ca/Policies/disclosure.
htm).
38. Personal Health Information
Protection Act, 2004, S.O. 2004,
c. 3, Sched. A, s.12(1).
39. Physicians should be aware that
this document provides an over-
view, not a detailed account of all
the ways that they are account-
able to the College. The role of
the College, its authority and
powers are set out in the Regu-
lated Health Professions Act
(RHPA), the Health Professions
Procedural Code (Sched. 2 of the
RHPA) and its regulations (O.
Reg 39/02, 107/96, and 59/94)
and the Medicine Act and its reg-
ulations (O. Reg. 114/94, 856/
93, and 865/93 (all available
online by typing in the name of
the relevant Act at www.e-laws.
gov.on.ca/navigation?file=brows
eStatutes&reset=yes&menu=bro
wse&lang=en (Accessed: 2009
Mar 12).
40. Regulated Health Professions Act,
R.S.O., 1991, c.18, Sched. 2.
Available online at www.search.
e-laws.gov.on.ca/en/isysquery/
a741833c -4193- 4cf7-b90c-
99cd8260849c/1/frame/?search
=browseStatutes&context=
(Accessed: 2008 Dec 17).
41. Canadian Medical Association
(1868). CMA Code of Ethics
(updated 2004). Available online
at http://policybase.cma.ca/
PolicyPDF/PD04-06.pdf
(Accessed: 2008 Oct 9).
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