A facility director must promptly inform the College when there is a “significant or material renovation” to the facility. What does this mean?
An example of a significant renovation would be adding a treatment room or a surgical suite. A material renovation would be re-locating an X-ray machine, for example. If you are planning a renovation, you can contact the College for further direction on whether it requires any action on your part for accreditation.
A facility director must provide the College with a written undertaking to indicate that they are responsible for the oversight of the accreditation of the veterinary facility. How is this undertaking provided to the College?
The undertaking with the College is the facility director’s agreement to accept the obligations, as outlined in the Policy Statement: Facility Director - Accreditation, for the oversight of the accreditation of the veterinary facility. This occurs when the facility director applies for inspection of the facility in the Professional Practice Portal. This form is kept on file at the College.
Can a facility director fulfill their role and responsibilities if they have not worked at or been on-site at the facility for which they are accountable? Can this role be done virtually?
The facility director’s role is to provide oversight of the facility, which may require them to be on-site as needed. When a facility director cannot be on-site at the facility, they must be available by phone. It is an expectation of the College that the facility director is present at the time of inspection to discuss the outcome with the College’s inspector.
Does a facility director have a conflict of interest if they are an employee at the facility?
A veterinarian has a conflict of interest if a non-veterinarian employer or contractor exercises control or influence over clinical or professional aspects of the veterinarian’s work. If this occurs, the veterinarian must manage the conflict of interest. In their undertaking with the College, the facility director undertakes to ensure only licensed veterinarians exercise control over or influence the clinical and professional aspects of the provision of services through the facility and that they maintain the standards of practice of the profession. For more information about conflict of interest, see the Guide to the Professional Practice Standard: Conflicts of Interest in the Practice of Veterinary Medicine.
How many days constitute an absence, where the facility director must arrange for another veterinarian to assume the role?
The College does not define how many days would constitute an absence. There may be circumstances where it’s necessary to arrange for another veterinarian to assume the role because the facility director is unable to, such as during a long-term absence from the practice. If the facility director is still reachable and accessible, then they may only need to assign certain responsibilities during that time they are away from the practice, such as during a vacation or short-term illness. Factors to consider include the length of absence from the practice, or if an absence prevents the facility director from being reachable or accessible by the veterinary team or the College to make decisions relating to facility accreditation. In certain circumstances, it may be advisable to apply to the College for a change of facility director, even if the absence is intended to be temporary. This can vary case‐by‐case, so it is suggested to contact the College if guidance is needed.
If a facility director wishes to assign some responsibilities to another veterinarian, does the arrangement need to be in writing?
The process for assigning responsibilities is between the facility director and their colleague(s) and they can decide whether it requires something in writing. The College does not require anything to be submitted and any process that is used to assign responsibilities is between the facility director and their colleague(s).
If I am taking over as a facility director at a hospital for a few months, how do I change the name of the facility director with the College?
The veterinarian who is listed as the current facility director needs to log into the Professional Practice Portal on the College website, go to Forms and Applications, and click on Facility Accreditation. Then they need to click on Change of Information for Accredited Facility, and complete the Change in Director form. This will not prompt an inspection.
If there is a complaint about a facility, is the facility director responsible for responding to the complaint?
Yes. As the veterinarian who has oversight of the facility, the facility director is accountable to the College for ensuring the facility is meeting the requirements for the Certificate of Accreditation. If the College receives information that indicates the veterinary facility is not meeting its obligations with respect to the certificate, the Registrar can cause an inspection of the facility. In certain circumstances, the College may also begin an investigation into professional misconduct on the part of the facility director.
It is a facility director’s responsibility to ensure the facility meets all applicable federal, provincial, and municipal standards. What does this mean?
The College expects that facility directors are following all laws that apply to the facility. This includes the College’s legislative requirements and facility standards. In addition, there are requirements under federal legislation, such as the Controlled Drugs and Substances Act. It includes provincial legislation related to X-ray machines under the Ministry of Labour, Radiation Protection Services. Municipal standards include building codes and permits and proper disposal of hazardous materials.
Should a change in facility director take place if a locum veterinarian covers for a one-veterinarian practice?
In most circumstances, a locum is providing relief for a temporary period, such as a vacation. If the facility director is still accessible and reachable, then they would not need to apply for a change in facility director in most circumstances. But if the locum is covering for a period when the facility director is not going to be reachable, then a change in facility director may be advised.
When an owner of a veterinary facility is not the facility director, what responsibilities does the owner have in relation to facility accreditation?
When a facility director for the purpose of accreditation is not an owner or partner in the practice, the owners or partners of the facility must authorize another licensed veterinarian to act as the facility director. The facility director submits to the College the written authority of the owners or partners of that facility to act as the facility director related to facility accreditation.
Why is it necessary for the facility director’s name and contact information to be posted in the facility? And how can this be posted?
The reason for displaying the name of the facility director responsible of accreditation is for transparency to the public. It assists clients and staff to know which veterinarian is responsible for ensuring that the facility meets the expected standards of accreditation. The person taking on this role may not necessarily be the person in charge of other aspects of the practice. The role of the facility director is very specific in terms of the responsibilities and accountabilities to the College with respect to facility accreditation.
How this is displayed in the practice is at the discretion of the facility director.
If a facility director wishes to assign their responsibilities to another licensed veterinarian, how much can they assign before they should consider changing the facility director?
The facility director can assign some responsibilities to other veterinarians or to other team members, but it is not the intention that they would assign all of them. If it is the intention that another veterinarian take on the primary role and responsibilities for meeting the facility standards, then there should be an application to the College for a change of facility director.