Assessors follow real patients, read records and talk to staff at every level. A CPSBC team uses patient tracers over one or two days, Accreditation Canada ends an ICHSC inspection with a verbal report, and the CPSO sends a nurse inspector to each out-of-hospital premises.
How the day runs, body by body
| Body | Who comes | What they do | How it ends |
|---|---|---|---|
| CPSBC, BC facility | NHMSFAP staff and peer assessors, matched to the anesthesia level, size and complexity | Patient tracers from admission to discharge, document review, and protocols that set the questions | A verbal summary, including any critical or high-risk nonconformance |
| Accreditation Canada, Ontario ICHSC | A team leader and peer-matched assessors, with a surgical physician or a nurse for surgical centres | An opening meeting, interviews, observation and document review against checklists | A verbal inspection report, and the written report within 14 days |
| CPSO, Ontario OHP | A nurse inspector appointed by the CPSO | An inspection of the premises against the OHP standards | An outcome from the Premises Inspection Committee |
| Collège des médecins du Québec | An inspector, and an expert physician where needed | A tour of the place of practice, then a review of selected records | A directed interview and the preliminary findings |
The CPSBC asks facilities to book procedures on the assessment day, with fewer patients, so the assessors can observe the full scope of service, and to give them a room to work in.1 Accreditation Canada's ICHSC visit lasts one or two days, depending on the size and scope of the centre, and involves conversations with many levels of staff.2
What happens if they find a problem
A CPSBC critical nonconformance must be fixed before further patient care, and is reported within two business days. High-risk findings follow within seven calendar days, with seven days to respond, and the final report within 45 days, with 90 days to respond.1 An ICHSC finding with potential for immediate harm goes to an urgent meeting of Accreditation Canada's Advisory Panel, and the Ministry is told at once.2 After a CPSO Fail, all OHP procedures stop.3 In Quebec, the Collège's inspection ends with a directed interview to validate what the records showed.4
- Schedule the right cases. Procedures that show your full scope, with time left for staff to talk.
- Name your guides. One person who walks the assessors through, and one expert per area, from recovery to reprocessing.
- Prepare the room. A quiet room, the policy manual, personnel files, maintenance records and access to the charts.
- Let staff answer. Assessors ask the people doing the work, so brief them on where the evidence lives.
- Write down every finding. At the verbal summary, record each finding, its risk level and its deadline.
- Date ______ Body ______ Team leader ______
- Our lead ______ Area experts ______
- Cases booked ______ Tracer patient ______
- Assessor room ______ Records access set up ______
- Findings at close ______ Risk level ______ Due ______
Questions
How long does a CPSBC assessment take?
One to two days, six to eight hours a day, depending on the complexity of the services.
Do Accreditation Canada assessors sample records?
Yes. They choose samples by judgement, from the services done that day and those that carry the most risk.
Can we object to an assessor?
Yes, for a conflict of interest. Both the CPSBC and Accreditation Canada share the assessors' names before the visit.
Sources
- 1College of Physicians and Surgeons of British Columbia, 2026NHMSFAP Accreditation Manual, version 1.2, effective 1 April 2026Read source
- 2Accreditation Canada, 2026ICHSC Quality Assurance Program Information, version 2.5Read source
- 3College of Physicians and Surgeons of Ontario, 2026Out-of-Hospital Premises Inspection Program overviewRead source
- 4Collège des médecins du Québec, 2026Surveillance individuelle des médecins, inspection professionnelleRead 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.