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 in one of two ways:
1. when the facility director applies for inspection of the facility in the Professional Practice Portal or
2. by completing the form Notification of Change of Facility Director of an Accredited Facility.

The facility director must be engaged in the practice of veterinary medicine conducted in or from the facility. The College does not define how often the facility director must work at or be on-site at the facility.

The facility director is responsible for the oversight of the accreditation of the veterinary facility, which requires them to be on-site as needed and have a working understanding of the practice of veterinary medicine conducted in or from the facility. When a facility director is not on-site working 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.

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 will have responsibility for and control over all of 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. 

The College does not define how many days would constitute an absence. There may be circumstances where it’s necessary to arrange for another licensed 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.

 

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).

The facility director can assign some of their responsibilities to other licensed veterinarians in the practice, but it is not the intention that they would assign all of them. If it is the intention that another licensed veterinarian take on the primary role and responsibilities for meeting the facility standards, then the College must be notified immediately of a change of facility director. 

The facility director can assign some responsibilities to capable members of their team, who are not licensed veterinarians, to assist them with meeting the facility standards. The facility director remains responsible for any tasks they assign to their team members.

The licensed veterinarian who is listed as the current facility director would need to  go to the College website and fill out the form Notification of Change of Facility Director of an Accredited Facility. This will not prompt an inspection and there is no fee.

 

If someone has a concern about a veterinary facility not complying with the accreditation standards, this concern would not be investigated through the complaints process. If a concern is brought to the College’s attention, the Registrar may cause an inspection of the facility to determine if the facility is being operated under and in accordance with the certificate of accreditation. The inspection report would be reviewed, and any action the College takes will impact the certificate of accreditation, not the Facility Director’s licence. It is rare for the College to receive serious concerns about a facility. In exceptional circumstances, an inspector may identify serious concerns about the conduct of the Facility Director, and these may be brought to the Registrar for review. This only happens if public safety is a significant concern.

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. 

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. 

If any of the following events occur, the College must be immediately notified:

1. Any change to the name of the veterinary facility.
2. Any change in the type of species treated in or from the facility.
3. Any change in the scope of veterinary services offered in or from the facility.
4. The relocation of the veterinary facility or of a stationary element of a facility with a mobile element.
5. Any change in the identity of the facility director.
6. The facility no longer has any members who would satisfy the requirements set out in paragraph 3 of subsection 11 (2).

It is the responsibility of the owner(s) of the veterinary facility to immediately inform the College of any of the above events. However, where a facility director is not an owner of the facility, the facility director may inform the College on the owner’s behalf. If there is a change in the identity of the facility director, or the facility no longer has a facility director, the owner(s) of the facility must inform the College.  

 

In sole proprietorships the owner of the facility will also be the facility director, so they would fulfill the role and responsibilities of both the owner (holder of the certificate) and the facility director.

The owner of the veterinary facility or a partner in the practice conducted in or from the facility is the holder of the certificate of accreditation. They must immediately inform the College if any of the following events occur:

1. Any change to the name of the veterinary facility.
2. Any change in the type of species treated in or from the facility.
3. Any change in the scope of veterinary services offered in or from the facility.
4. The relocation of the veterinary facility or of a stationary element of a facility with a mobile element.
5. Any change in the identity of the facility director.
6. The facility no longer has any members who would satisfy the requirements set out in paragraph 3 of subsection 11 (2).

They must ensure that the certificate of accreditation is posted visibly in the veterinary facility; or in the case of a mobile facility, makes the certificate of accreditation available for review upon request.

In practices where an owner of the facility is not the facility director, there are different people filling these roles – one is both the owner and the holder of the certificate of accreditation, and the other is the facility director.

 

When a facility director is not an owner or partner of the facility, the facility director must include in their application for the issuance or renewal of a certificate of accreditation a written attestation from the owners or partners, as the case may be, that the facility director is authorized to be the facility director and is authorized to provide the undertaking for the oversight of the accreditation of the veterinary facility.

The role of the facility director is very specific in terms of the responsibilities and accountabilities to the College with respect to facility accreditation.  The reason for displaying the name of the facility director is to assist 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.  How this is displayed in the practice is at the discretion of the facility director.