The Practice Enhancement Program is an educational program designed to offer the physicians of Saskatchewan a report of the quality of their practices through a practice-based assessment process and to encourage continual improvement of physicians’ clinical skills and office practices in order to provide high quality patient care to Saskatchewan residents.


The Practice Enhancement Program is supported through equal funding annually from the College of Physicians and Surgeons of Saskatchewan, Saskatchewan Health of the provincial government and the Saskatchewan Medical Association and is accountable to each organization for providing annual aggregate statistical information on assessments completed and financial program expenditure.


The Practice Enhancement Program is administered by a committee of six Saskatchewan physicians appointed by the College of Physicians and Surgeons of Saskatchewan, three of whom are nominated by the Saskatchewan Medical Association. The committee is Co-chaired by a nominee from the College of Physicians and Surgeons of Saskatchewan and a nominee from Saskatchewan Medical Association.

The PEP committee functions independently of the organizations represented. Information obtained in the process of an office assessment remains the property of the Practice Enhancement Program and cannot to be used by any committee of the funding organizations for any disciplinary purpose.

The program is based on the assumption that an experienced physician can review another physician’s office facilities, procedures and medical records and, in combination with feedback from patients of that physician, come to a valid determination of the quality of care being provided by that physician. The committee meets regularly to review information gathered by the assessors and to make the final decision on the quality of care provided by each physician. This will enable unbiased and objective categorization of quality of care.

The tracking of aggregate information will be maintained by the Practice Enhancement Program Office. Information will be reported to the three supporting organizations as follows:

  • minutes of committee business meetings
  • annual statistics of program activity
  • semi-annual and year end fiscal reporting


Assessments will be carried out by trained Saskatchewan Physician Assessors selected by the Practice Enhancement Program Committee based on the following criteria:

The physician assessor:

  1. Has had an office assessment carried out on his/her practice.
  2. Will have practiced in Saskatchewan for five or more years, and must be currently in practice.
  3. Must be willing to commit to carrying out four to ten assessments per year.
  4. Will not have been a subject of a review with adverse conclusion within the last five years from the College of Physicians and Surgeons of Saskatchewan, the Joint Medical Professional Review Committee, or any significant body determining adequate competency.
  5. Is not a current member of the College Council, SMA Board or the Joint Medical Professional Review Committee (JMPRC).

Selection of Physicians Eligible for Assessment

All Saskatchewan practicing physicians are eligible to participate at least once every five years.
Possible exemptions:

a) physicians completing a residency within the previous five years.

b) physicians in exclusively administrative roles or hospital-based practice such as administrative medicine, emergency and laboratory medicine.

c) physicians who have been assessed within the past five years.

d) physicians who have not practiced in Saskatchewan for at least three years.

Selection is based on a stratified randomized selection

Under no circumstances will assessments be conducted on physician practices referred to the Practice Enhancement Program or requested by a physician to fulfill a requirement of another agency.

Streaming Process:


The Practice Enhancement Program will stream physicians using information from the following:

  • MCC360 Multisource Feedback Survey
  • MCC360 Telephone Interview – provided by a trained peer assessor
  • Risk criteria developed by the PEP committee.

The risk criteria are derived from robust experiences elsewhere and include: age of the practitioner; whether practice is solo or with a group; whether the practice is rural or urban; whether the practice includes work in a hospital; whether there is a faculty appointment; and, whether the practitioner has learners for teaching purposes attending his/her practice.

Neither the MCC360 Multisource Feedback Survey, telephone interview, nor the risk criteria can be definitive in establishing whether the practice is of high quality or problematic, but may be suggestive and will be considered by the Practice Enhancement Program Committee in its judgement when streaming physicians.

In order to adhere to PEP’s mandate, some physicians will be randomly placed in Stream 2, regardless of their results on the MCC360 survey or any risk criteria.


Stream 1:      Assessment is complete. No further action required.

Stream 2:      A Complete In-office Assessment is required and additional information will be requested. This stream will include a chart review, facility review, as well as a face to face interview with one of PEP’s trained assessors.




The Practice Enhancement Program Committee will categorize the physician on the following basis:

Category 1      Consistent good care, no concerns re: patient care or records
Category 2      Acceptable, but significant need for improvement in areas listed
Category 3      Immediate Cause for Concern – Serious risk of harm to a patient

Follow-up action per category:

Category 1      full accreditation, no review for at least five years
Category 2      necessitates planned follow-up
Category 3      referred to the College