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Quality Assurance Program (QAP) audit criteria

qap_symbol_and_noticeThe QAP requirements are defined by Ontario Regulation 207/94 under the Medical Laboratory Technology Act, 1991 (MLT Act). The QAP is comprised of three components: Professional Portfolio, Practice Review, and Competence Evaluation. Additionally, registrants self-declare compliance with a series of Quality Assurance declarations annually during the Registration renewal process. The Quality Assurance Committee is responsible for approving the program’s criteria. QAC policy 42 Quality Assurance Program audit criteria is available here. Below, you will find a summary of each QAP component and its applicable criteria.

Quality Assurance Declarations 

- All Practising registrants must review and self-report compliance with five Quality Assurance declarations during the annual renewal process.
- Registrants self-report compliance with the following declarations:  

    - I complied with the CMLTO Standards of Practice and Code of Ethics.
    - I am competent to practise as a medical laboratory technologist.
    - I understand that it is my professional obligation to maintain an up-to-date Professional Portfolio.
    - I understand that it is mandatory for Practising registrants to participate in the
       CMLTO Quality Assurance Program.
    - I understand that I must submit to the College my self-assessment and learning goals by March 31st


Professional Portfolio

  • Every Practising registrant must submit the following Professional Portfolio sections by March 31st for review by QAP staff:
    • Professional Profile
    • Self-Assessment
      • Completed self-evaluation of MLT tasks and responsibilities
      • Completed CMLTO Standards of Practice self-assessment
      • Completed Practice Improvement Self-Assessment Module (PRISM)
    • Learning goals
      • Two learning goals with at least one based on an area of improvement identified by the self-assessment. Only the Goal and Goal Description sections must be submitted by March 31st.
  • Practising registrants are randomly selected once every five (5) years to submit their comprehensive Professional Portfolio for review by the Quality Assurance Program staff. Randomly selected registrants are required to submit the following by December 31st.
    • Confirmed Professional Profile information (completed by March 31st)
    • Completed self-assessment (completed by March 31st)
    • Learning goals with the following sections completed:
      • Goal (completed by March 31st)
      • Goal Description (completed by March 31st)
      • Impact on Practice
      • Goal completed
      • If Goal completed is No or Ongoing, the Next steps are recorded.
    • Completed Professional Development requirements and hours
      • A minimum of three different activity types
      • A minimum of three activities linked to a learning goal and a description of how the activity supported their continued competence.
      • A minimum of thirty (30) professional development hours with key learnings that clearly describe how it advanced the registrant’s professional knowledge, skill, and/or judgment.
  • Practising registrants who register with the College in the current portfolio year will not be selected to submit their Professional Portfolio. The first calendar year of CMLTO registration does not contribute to the five (5) year cycle but they are still required to maintain an up-to-date professional portfolio.
  • A Practising registrant may be required to submit their Professional Portfolio within thirty (30) days upon request by the Quality Assurance Committee.
Practice Review Assessment
  • Practising registrants registered with the CMLTO for more than two (2) years will be randomly selected once every ten (10) years to complete the Practice Review assessment.
  • A Practising registrant will be required to complete the Practice Review assessment based on the following Quality Assurance Committee criteria:
    • All Practising registrants will complete the Practice Review within their first two (2) years of CMLTO registration.
    • A registrant who changes their class of registration from Non-Practising to Practising will complete the Practice Review within two (2) years of the change.
    • A registrant suspended for non-payment of fees and who reinstates as Practising will complete the Practice Review within two (2) years of reinstatement.
    • A registrant who Resigns or is revoked and reapplies to the CMLTO as Practising will complete the Practice Review within two (2) years of re-registering.
    • A registrant who changes their class of registration (i.e., Resigned, Non-Practising, suspended, or revoked) after being randomly selected for the Professional Portfolio or Practice Review audit will complete the Practice Review assessment within 60 days of returning to Practising status.
    • A Practising registrant may be directed to complete the Practice Review assessment within a specified timeframe if the Committee upon review of a registrant’s case determines that a Practice Review assessment will support the registrant’s continued competence.
Competence Evaluation
The CMLTO QAC may require a registrant to participate in a Competence Evaluation assessment if the Committee is of the opinion, based on a review of the registrant’s Professional Portfolio, the results of a practice review or any other relevant written information, that the registrant’s knowledge, skill, and judgment are unsatisfactory.

Failure to comply with any of the QAP criteria may result in referral to the QAC

Failure to comply with the QAP and Case Referral to QAC:

Failure to comply with any of the Quality Assurance Program criteria may result in referral to the Quality Assurance Committee (QAC). Cases are referred to the QAC in accordance with QAC Policy 45 Case Referral (here). Referrals may include:
  • An audit exclusion or extension request falls outside of the QAP administrative decision-making policy,
  • Registrant fails to meet a requirement of the QAP:
        -  Does not submit a complete Stage 1 or Stage 2 Portfolio, even after
              coaching and/or intervention by QAP staff, as appropriate, or

        -  Does not meet the minimum Practice Review assessment
               criteria in alignment with QAC Practice Rewview Policies

  • A Practising registrant fails to respond or communicate with the CMLTO in a complete or timely manner as described in the notices or communications sent to the registrant.
  • A registrant's QA declaration non-compliance is not described in policy QAC 40 – MLTs not Compliant with QA Declarations at Annual Renewal.

The QAC may take one or more of the actions defined in Section 80.2 of the Health Professions Procedural Code (Schedule 2 of the Regulated Health Professions Act, 1991).