Prepare for Inspection
The College has put together a list of resources that can help ensure success in your inspection. It is important that Facility Directors review all the resources on this page prior to the inspection day.
Sample inspection checklists
Checklists specific to the type of facility that will familiarize you with the accreditation standards to achieve a Certificate of Accreditation. Printing the checklist can be helpful for conducting a mock inspection prior to the College’s inspection.
Click on the facility type as it applies to you for sample checklists. (PDFs available for download):
Companion animal hospital
Companion animal office
Companion animal mobile office
Companion animal mobile
Companion animal emergency clinic
Companion animal spay-neuter clinic
Food-producing animal hospital
Food-producing animal mobile
Emergency Equine mobile
Remote Area Companion animal mobile
Specialty animal hospital – dentistry
Specialty animal hospital – ophthalmology
Specialty animal hospital – companion animal referral hospital
Information on controlled drug management
Tips and resources for managing controlled drugs and completing audits at your facility. Click to view the page.
Click on this link to view sample templates for documents such as invoices (fees for drugs and services), radiology and surgery anesthetic logs.
Gas Scavenging System
The College’s facility accreditation program assures the public that all veterinary facilities provide a professional and safe environment for patients, clients, and staff.
The College Council establishes the facility standards that all veterinary facilities must meet for accreditation. All accredited veterinary facilities are under the oversight of a licensed veterinarian who is designated the facility director for the purposes of accreditation. The facility director is responsible for ensuring that a veterinary facility is operated in accordance with the facility standards and meets these standards for the duration of the certificate of accreditation. Involving veterinary team members in facility accreditation helps ensure that everyone is aware of how the veterinary facility is meeting the College’s standards.
In the Minimum Standards for Veterinary Facilities in Ontario, there is a requirement for a hospital to have a gas scavenging system contained in the anesthesia area which complies with the requirements of the Occupational Health and Safety Act (OHSA). This standard is in the spirit of adhering to the main purpose of OHSA which is to protect workers from health and safety hazards on the job.
Waste anesthetic gases (WAG) are anesthetic vapours, that leak into the surrounding environment and can result in worker exposure. The sources of WAG are leaks from anesthetic equipment, improper installation of scavenging systems, leaks from patient’s masks and exhalation of gases by patients. Short term exposure to WAG can cause fatigue, drowsiness and headache. Anesthetic gases cannot be detected by odour until their concentrations are much higher than occupational exposure limits. Therefore, the proper maintenance of the gas scavenging system plays a valuable role in protecting you and your veterinary team members.
In an effort to assist facility directors in complying with this requirement, the Accreditation Committee of the College has clarified that at inspection, the facility director is expected to provide documentation to an accreditation inspector that the gas scavenging system has been inspected and verified by a qualified technician from an independent third-party company within the previous 24 months or within the timeframe recommended by the manufacturer.
The Accreditation Inspectors will continue to also inspect:
hose connections for obstructions or kinks.
tubing connected to the exterior of the building for vent coverage.
local exhaust or room ventilation to ensure that it is functional.
charcoal filters to determine if they are checked and/or replaced on a regular basis by veterinary facility staff.
It is a reasonable expectation for facility directors to ensure the safety of hospital staff, clients and patients based on the hazards that exist in the hospital. Effective scavenging of waste anesthetic gas is a crucial method of decreasing exposure in the veterinary practice.
If you have questions about facility accreditation and inspections, contact Aneeta Bharij, Principal Accreditation, email@example.com or ext.2230.
Efficiency in record keeping - anesthetic logs
The College places a strong emphasis on supporting high quality medical records. Medical records are central to safe quality veterinary medicine and provide the basis for continuity of care.
The Minimum Standards for Veterinary Facilities in Ontario (MSVFO) outlines the medical record requirements that need to be met for a Certificate of Accreditation. During an inspection, Accreditation Inspectors ensure that the medical records kept in a facility meet these requirements.
In the MSVFO, there is a requirement for veterinary facilities to keep an anesthetic log, either alone or in combination with a surgical log. There is also a requirement to keep an anesthetic monitoring chart. In reviewing these requirements in the MSVFO, it was determined that most of the information that is documented in the anesthetic monitoring chart is duplicated in the anesthetic/surgical logs. To address efficiency in record keeping and reduce duplication of information an alternative method to meet the anesthetic/surgical log requirements was considered.
Now, veterinary facilities can maintain the anesthetic/surgical log by compiling patient anesthetic monitoring charts in chronological order. This can be paper copies of the anesthetic monitoring charts in a binder, scanned copies in an electronic file, or electronic copies in a file that can easily be accessed and printed. A copy of the anesthetic monitoring chart should also be kept in the patient’s individual medical record. By doing this, the veterinary facility will not need to also keep a separate anesthetic/surgical log.
This is effective as of August 1, 2020.
CPS- Compendium of Pharmaceuticals and Specialties
Click on the link to view relevant laws, regulations, standards, and by-laws.
What to expect on inspection day and afterwards?
During the inspection, your inspector assesses the facility for compliance with the standards, recognizes what your practice does well, and may offer suggestions on opportunities for improvement if applicable.
The inspection will take approximately 1.5 hours to complete. You do not need to close your practice, change appointments, or operate your facility any differently.
During the inspection, your inspector will need at least one staff person to accompany them during the on-site visit, answer questions, and be the main contact person. And at the end of the inspection, the facility director must be present to discuss the outcome of the visit. You do not need to pull medical records before the inspection. Your inspector will decide on the day of your inspection what cases and medical records they will need to review. This may include surgical, dental, inpatient, etc. They will likely request medical records from each veterinarian.
If your inspection notes full compliance with the standards, the Certificate of Accreditation will be issued for a 5-year term and mailed to you. If there are deficiencies noted, you will receive an inspection report and be provided with 30 days from the date of the inspection to provide evidence of compliance with the requirement(s).
Here to assist you
We understand that having your facility inspected and accredited is an important part of your role as a facility director, and we want to support you with clear information about our processes in accordance with our Service Commitment.
You are welcome to email us at firstname.lastname@example.org with any further questions.