Work back from the notice each body gives, and keep the records ready all the time. The CPSO inspects every out-of-hospital premises every four years, Ontario gives an ICHSC four months' notice of its Accreditation Canada inspection, and the CPSBC writes about nine months before a BC facility's accreditation expires.
The notice each body gives you
| Body | Notice | Before the visit | The visit |
|---|---|---|---|
| CPSO, Ontario OHP | A routine inspection every 4 years, or sooner | The Medical Director's annual attestation | A nurse inspector appointed by the CPSO |
| Accreditation Canada, Ontario ICHSC | 4 months' written notice from the Ministry, and a first contact 12 to 14 weeks ahead | Selected documents about 1.5 months ahead | One or two days, with a peer-matched team |
| CPSBC, BC facility | A letter about 9 months before expiry, and the documentation package about 6 months before | A self-assessment against every criterion, and a teleconference 1 to 2 weeks before | One or two days of six to eight hours, using patient tracers |
| Accreditation Canada, Qmentum Global | A four-year cycle | Self-assessment, survey instruments and attestation | A short-notice on-site assessment |
The CPSO's Premises Inspection Committee decides Pass, Pass with Conditions or Fail, and a Fail stops all OHP procedures.1 Accreditation Canada asks an ICHSC for its documents so assessors can prepare, and says this is not an opportunity for advance consultation.2 The CPSBC sends a pre-accreditation questionnaire that mirrors the standards.3
Run your own inspection first
Read your records as the inspector will. Each Medical Director in Ontario affirms compliance with the OHP standards every year and is accountable for them.5 Qmentum Global builds the same habit into its cycle, with self-assessment and attestation before the on-site visit.4 Pull five charts a month, check every one is complete, signed and timed, and fix what you find before anyone asks.
- Diarise the cycle. The date of your last visit, the notice period, and the date by which documents are due.
- Name an owner for each standard. One person who answers for it, and who holds its evidence.
- Self-assess against every criterion. Use the body's own questionnaire or tool, and rate yourself honestly.
- Close each gap with a date. Every gap gets an action, an owner and a deadline.
- Audit charts every month. Five charts, read for completeness, signatures and times.
- Brief the team. Who greets the assessors, who walks them through a patient's care, and where they work.
- Body ______ Last visit ______ Next window ______
- Documents due ______ Sent on ______
- Standard ______ Owner ______ Self-rating ______
- Gap ______ Action ______ Due ______
- Charts audited this month ______ Issues ______
- Team briefed on ______
Questions
How often does the CPSO inspect an out-of-hospital premises?
Every four years as routine, or more often if the CPSO decides it is necessary.
How much notice does an Ontario ICHSC get?
Four months' written notice from the Ministry of Health. Reactive inspections may come with less.
Can a BC facility move its assessment date?
Only for unforeseen extenuating circumstances. Cancelling less than six weeks before the date may cost a $500 rescheduling fee.
Sources
- 1College of Physicians and Surgeons of Ontario, 2026Out-of-Hospital Premises Inspection Program overviewRead 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
- 4Accreditation Canada, 2025Qmentum Global for Canadian Accreditation, programme overviewRead source
- 5College of Physicians and Surgeons of Ontario, 2026Medical Director StandardRead 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.