A policy and procedure manual staff have read, current staff records, complete patient charts, quality assurance minutes and an incident and complaints process. The CPSO lists the areas a premises' policies must cover, and the CPSBC asks for personnel files, patient records, the policy manual and maintenance records on the day.
What each body asks to see
| Document | CPSO, Ontario OHP | Accreditation Canada, Ontario ICHSC | CPSBC, BC facility |
|---|---|---|---|
| Policy and procedure manual | Covers the areas in Appendix B of the Medical Director Standard, read by staff on hire, every year and after a change | Selected documents sent ahead, such as policies and procedures | The facility policies and procedures manual |
| Staff records | Current records for each person, with qualifications, experience and any hospital privileges | Organizational structure, personnel policies and training | Personnel files of all staff |
| Quality assurance | At least two QA committee meetings at each site each year, with attendance | A quality management system | The quality assurance manual and documentation, and drill records |
| Patient records | A selection reviewed for completeness and accuracy | Records sampled from the services that carry the most risk | Patient medical records, traced |
| Complaints | Your own process | A complaints record reviewed for trends every quarter | The facility's complaints process |
The CPSO's Medical Director Standard requires policies and procedures on the issues in its Appendix B, reviewed and updated regularly, and staff confirm they have read the manual.1 Its Quality Assurance Standard asks for two QA meetings a year at each site, minuted with who attended, and a regular review of patient records.4 An Ontario ICHSC keeps a complaints record for at least three years.5
A policy only counts when staff follow it
Accreditation Canada rates a requirement met in practice but missing its documentation as a minor non-conformance, and a process that exists but is not followed most of the time as a major one.2 The CPSBC accepts policies, procedures, staff signatures, photographs and records as evidence, and does not accept draft documents.3
- List the areas each body names. The CPSO's Appendix B, the ICHSC Standard's sections, or the NHMSFAP standards that apply to your class.
- Write one policy per area. Short, dated, approved by the medical director, with an owner.
- Get every reader's confirmation. On hire, every year, and after each change.
- Keep staff files current. Registration, qualifications, training and privileges, checked before each person starts.
- Minute every quality meeting. Who attended, what was reviewed, and what changed.
- Point each policy at its proof. The record that shows the policy is followed, such as the signed note or the consent at booking.
- Policy ______ Area ______ Owner ______
- Approved by ______ On ______ Review due ______
- Staff who confirmed reading ______
- Where the proof lives ______
- Last changed ______ Reason ______
Questions
How does wai show our policies being followed?
wai keeps the records that show each policy in practice, such as consent taken at booking, signed notes and the audit trail.
How often do staff have to read the OHP policy manual?
On hire, every year, and after any change, with a confirmation that they have read it.
Does the CPSBC accept draft policies as evidence?
No. Draft documents are not accepted as evidence of a remediated nonconformance.
Sources
- 1College of Physicians and Surgeons of Ontario, 2026Medical Director StandardRead source
- 2Accreditation Canada, 2026ICHSC Quality Assurance Program Information, version 2.5Read source
- 3College of Physicians and Surgeons of British Columbia, 2026NHMSFAP Accreditation Manual, version 1.2, effective 1 April 2026Read source
- 4College of Physicians and Surgeons of Ontario, 2026Quality Assurance StandardRead source
- 5Government of Ontario, 2026O. Reg. 215/23 under the Integrated Community Health Services Centres Act, 2023Read source
Written by the wai team from Accreditation Canada, the CPSO, the CPSBC and Santé Québec guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither Accreditation Canada, the CPSO, the CPSBC nor Santé Québec endorses wai or any software.