Continuing Competence Program Manual

Introduction

As outlined in the HPA, Health Colleges are required to establish and maintain a Continuing Competence Program (CCP) in which regulated members must participate. The public benefits from the CCP due to a higher assurance of quality care, while ACSLPA regulated members of their respective professions benefit when all clinicians are supported and enabled to provide quality care to their clients.

The CCP is designed to engage regulated members in maintaining and enhancing their competence, assess members’ engagement in activities that maintain or enhance their competence, and support members whose competence to practice may be at risk. The program is comprised of three components on the right.

Who Needs to Participate in the CCP?

All ACSLPA regulated members on the general register must complete the CCP annually by December 31 in order to renew or obtain a practice permit for January 1 of the subsequent year.

November 2024

CCP Activities

The CCP activities are the professional development activities that must be completed annually by regulated members. These activities are designed to engage members in maintaining and enhancing their competence. Regulated members must complete all the following activities annually:

• Continuing Education Report,
• Peer Dialogue Reflection, and
• Risks and Supports Profile.

The CCP is completed through the regulated member’s portal on the College’s online reporting system. The program is available to regulated members throughout the year and must be completed and submitted by December 31^st of the same practice year.

Continuing Education Report

The Continuing Education Report aims to support regulate members’ engagement in continuing education activities that are meaningful and impactful to their practice. In this report, members are asked to indicate the continuing education activities that they undertook during the practice year, and to describe how these activities impacted their practice. There is NO minimum number of hours that regulated members need obtain every practice year.

To complete the Continuing Education Report, regulated members must:

• Identify two continuing education activities on which they would like to reflect on from the
  list above,
• Provide specific information about the identified continuing education activities, (e.g., title of activity, date of the activity, etc.)
• Describe in writing how they applied, or will apply, what they learned from the identified activities in their professional practice. Members must be specific about any changes in their own knowledge, skills, attitudes, judgment, and/or practice.

Peer Dialogue Reflection

The Peer Dialogue Reflection is designed to support the regulated member’s engagement with their peers to receive feedback and/or perspectives from trusted sources regarding professional issues related to their practice.

For the purposes of the CCP, the peer selected by the regulated member for dialogue must:

• Be a trusted colleague, with whom the regulated member can have an open and
  honest dialogue, and
• Have skills, knowledge, abilities, or expertise that are relevant to the professional
  situation discussed.

The peer selected by the regulated member does not have to be of the same profession as the regulated member and does not have to be a regulated member of ACSLPA. Regulated members are asked to keep their written submissions focused on the topic of their competence and must not provide personal or private details about their peer, their relationship with their peer, or any clients whose cases may have been discussed as part of the dialogue.

To complete the Peer Dialogue Reflection, regulated members must:

• Describe in writing:
• The situation they discussed with their peer,
• Their rational for their choice of peer (i.e., the relevance of the peer to the professional situation discussed), and
• How they applied, or will apply, what they learned from this dialogue in their professional practice. Members must be specific about how their own knowledge, skills, attitudes, judgment, and/or practice have changed or will change.

Risks & Supports Profile

Completing the Risks and Supports Profile requires the regulated member to reflect on the factors that may negatively impact their practice, and the contingencies that they have, or can, put in place to mitigate the risk of harm (e.g., resulting from errors or unsafe practice).

To complete the Risks and Supports Profile, regulated members must:

• Identify at least one support that they have in place that helps to maintain or enhance their practice from the list of supports provided, and
• Identify at least one risk that applies to their practice from the list of risks provided. For each
  risk identified:
• Describe how this risk adversely impacts, or could adversely impact, their professional practice and/or service provision, and
• Identify at least one support they have in place or could put in place to mitigate this risk.

CCP Audit

An audit of ACSLPA regulated members’ CCP submissions takes place annually. It is designed to ensure participation in the CCP. The requirements for successful completion of each of the CCP activities are shown in the table below.

Regulated members who are unable to meet all the above requirements in their written CCP submission are referred to the practice assessment stage of the CCP.

Audit Categories

The CCP audit takes place on a 5-year cycle, so that every regulated member on the general register is audited at least once every five years, unless a special circumstance applies. In addition, 2-3% of submissions will be randomly selected for a completion audit.

In addition to audits on the regular 5-year cycle, the following categories of members will be audited annually, based on the specific circumstance:

1. All new registrants of ACSLPA who obtained their practice permit between renewal cycles.
2. Any regulated member whose random selection for a completion audit reveals an incomplete submission.
3. Any regulated member who falls below the mandatory currency hours that are required for renewal are part of a special process to support their continued competence. Please refer to ACSLPA’s Registration Handbook for more detailed information on this audit category.
4. Any regulated members who the Competence Committee refers to audit.

CCP Assessment

Regulated members who are unable to meet the criteria for satisfactory completion of the CCP activities through their written submissions and who have been identified through the audit of their submission is referred to the assessment component of the CCP.

The CCP Assessment has a progressive approach, with two components:

1. Interview
2. Practice Assessment
   a. Record Review
   b. On-site Practice Visit

There are potential exit points after each component of the assessment. Regulated members who meet the criteria for successful completion at each component will exit the CCP, while those who do not meet criteria will be referred on to the next component. A remediation plan may also be developed for regulated members who undergo a practice assessment (see the section ‘Remediation Plan’).

Interview

The interview is the initial component of the CCP assessment. Written CCP submissions that are flagged as not meeting requirements during audit are referred to interview. The aim of the interview component is to better understand the regulated member’s CCP submission.

The regulated member’s CCP submission forms the basis for the interview; only those CCP activities where the member did not meet scoring requirements will be discussed. The interview provides the member with an opportunity to verbally provide additional or clarifying information. As needed, the interviewer may provide guidance to the regulated member to support their participation in the
CCP activities.

There are two potential outcomes for regulated members after the interview:

1. Exit the CCP: this occurs when the regulated member meets the requirements for satisfactory completion of the interview.
2. Refer to Practice Assessment: this occurs when the regulated member does not meet the requirements for satisfactory completion of the interview.

Record Review

The record review is the first stage of the practice assessment. It is intended to evaluate whether
the regulated member practices in compliance with ACSLPA’s practice standards. As needed, the assessor may provide guidance to the regulated member to support compliance with ACSLPA’s
practice standards. Record reviews will be completed for regulated members who are in clinical and
non-clinical roles.

Assessors will complete a review of the submitted redacted records to determine if the regulated member practices in compliance with ACSLPA’s code of ethics and standards of practice.

There are three potential outcomes for regulated members after the record review:

1. Exit the Practice Assessment: this occurs when the regulated member, through their records, demonstrates that they practice in compliance with ACSLPA’s code of ethics and standards of practice.
2. Remediation Plan: this occurs when the assessor notes minor deficiencies in the records reviewed. See the section “CCP Remediation Plans” below for more detailed information on this outcome.
3. Refer to On-Site Practice Visit: this occurs when the review of the regulated member’s records shows that the member is not practicing in compliance with ACSLPA’s code of ethics and standards of practice.

On-site Practice Visit

The purpose of the on-site practice visit is to gather direct observational information on the regulated member’s demonstration of the competencies in the National Competency Profiles and to determine if the regulated member practices in compliance with ACSLPA’s code of ethics and standards of practice. For regulated members in clinical roles, on-site practice visits will include observations of clinical interactions with clients (with client consent).

Regulated members in non-clinical roles who are referred for an on-site practice visit will undergo a chart stimulated recall (CSR). During the CSR, the member will be asked to clarify the issues arising from the documentation that they originally submitted for record review. They may also be asked to present other documentation for review which indicates that they meet minimum competence to practice standards, or to answer behavioural questions as evidence of meeting minimum competence standards.

There are three potential outcomes for regulated members after the on-site practice visit:

1. Exit the CCP: this occurs when the observation of the regulated member’s practice demonstrates that they practice in compliance with ACSLPA’s code of ethics and standards of practice.
2. Remediation Plan: this occurs when the interviewer notes minor deficiencies in observed practice. See the section “CCP Remediation Plans” below for more detailed information on this outcome.
3. Refer to the Competence Committee: this occurs when the on-site observation of the regulated member’s practice shows that they are not meeting minimum competence to practice requirements, as outlined in the Code of Ethics, Standards of Practice and competency profiles. See the section “Noncompliance or Unsatisfactory Completion of the CCP”, below, for more information on this outcome.

CCP Remediation Plans

Assessors who engage with regulated members during the record review and on-site practice visit stages of the CCP may in consultation with the Competence Committee develop a remediation plan for the member. Remediation plans target any practice area where minor deficiencies are observed, i.e., when there is no/minimal risk of harm to clients and when it is anticipated that any deficiencies can be readily remediated within a short timeframe (within the practice year).

The remediation plan will detail:

• The remediation activities that must be undertaken,
• The evidence that must be provided as proof of remediation, and
• The timeline for submission of evidence.

Completion of any remediation plans that are developed during any of the practice assessment stages, within the timeframes specified by the assessor, is a requirement of the CCP.

Noncompliance or Unsatisfactory Completion of the CCP

Regulated members are expected to comply with all components of the College’s CCP. Failure to complete or unsatisfactory completion of any portion of the College’s CCP will result in the regulated member being referred to the ACSLPA Competence Committee. This includes situations where the regulated member:

• Does not respond to attempts to contact them from ACSLPA staff, interviewers, or assessors regarding their CCP submission or practice assessment,
• Does not submit the required records for review if referred to the record review component of the practice assessment,
• Does not submit evidence of completion of their remediation plan within the specified timeframe,
• Unsatisfactorily completes their remediation plan (e.g., does not complete all the remediation activities in their plan, or completes a reflection that does not demonstrate that any learning or changes to practice occurred), or
• Demonstrates competence to practice concerns or a lack of competence during their record review or on-site visit.

In response to noncompliance or unsatisfactory completion of the CCP, the Competence
Committee may:

1. Direct the regulated member to undertake one or more remediation activities within a specified period;
2. Impose conditions on the regulated member’s practice permit, including conditions that:
   a. The regulated member practice under supervision,
   b. The regulated member’s practice be limited to specified professional services or to specified areas of practice,
   c. The regulated member refrain from performing specified restricted activities,
   d. The regulated member refrain from engaging in sole practice,
   e. The regulated member submit to additional practice visits or other assessments,
   f. The regulated member report to the Registrar on specified matters on specified dates,
   g. The practice permit is valid only for a specified purpose and time,
   h. The regulated member is prohibited from supervising students, other members, or other health professionals, and
   i. The regulated member completes the CCP requirements within a specified timeframe;
3. Refer the regulated member to the Complaints Director; or
4. Direct the Registrar to cancel the regulated member’s registration and practice permit.

Reconsideration of Decisions

Regulated members may request reconsideration of a decision at any stage in the CCP assessment by submitting a written request to the Competence Committee. A reconsideration may be requested if the regulated member has reasonable and compelling grounds to suggest they have not been given due process for any part of the CCP assessment. Reconsideration can be submitted within 30 days of receipt of a decision.

Appeals

According to Section 41 of the HPA, regulated members who have conditions imposed on their practice permit as a result of unsatisfactory completion or non-completion of the CCP, or who have their practice permits suspended can request a review by ACSLPA Council by submitting a written request with reasons for a review to the Registrar. The request for review by Council must be submitted within 30 days of being notified of practice permit conditions or suspension.

Confidentiality and Disclosure of CCP Information

Information related to participation in the CCP, including information disclosed in forms and documentation, is confidential, unless the Competence Committee feels a referral to the Complaints Director is necessary based on information obtained through the CCP that:

• the regulated member has intentionally provided false or misleading information;
• the regulated member displays a lack of competence that has not been remedied by participating in the CCP;
• the regulated member may be incapacitated; or
• the conduct of the regulated member constitutes unprofessional conduct that cannot be readily remedied by means of the CCP.

Information related to a failure or refusal to comply with the requirements of the CCP is not confidential and is considered unprofessional conduct and may result in sanctions.

Regulated members are required to retain documentation and records related to their CCP submission for at least two (2) years after the end of the registration year to which the document relates. ACSLPA retains submitted CCP forms electronically for at least five (5) years after submission.

Accommodation

Regulated members with a diagnosis of a disability, or those experiencing extenuating circumstances (e.g., serious illness of self or immediate family member, illness or death of family member, or sudden and unexpected changes to one’s personal circumstance), may request accommodation with respect to completion of any part of the CCP.

Regulated members requiring accommodation need to contact ACSLPA to identify:

• The CCP process for which an accommodation is required;
• The reason for the accommodation request; and
• Any specific accommodation that is being requested.

Regulated members are asked to contact the College as soon as they are aware that an accommodation for a CCP process is required. Accommodation requests are processed within 5 business days.

The CCP Coordinator will listen to the regulated member, discuss the accommodation requested, and work with the member to develop a plan. The member may be required to provide supporting documentation from a qualified health professional to support their request for an accommodation. Only medical information relevant to the accommodation will be requested.

The regulated member’s accommodation plan will remain confidential to the greatest degree possible.

More information on the College’s CCP can be found at https://www.acslpa.ca/members/continuing-competence-program/