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Practice Audit

Subject – Practice Audit

Policy – Practice Audit

Policy: The purpose of this policy is to ensure that the highest quality of opticianry services are provided to the public through the use of a formal, confidential statute directed process that is reflective, useful, effective, educational (two way) and founded on conscious competence.

Goals To:

  • allow registrants to showcase their competence, growth and development by providing a positive learning experience
  • provide practice support in any deficient areas of a registrant’s practice as identified through the Practice Audit process


Selection of Participants Registrants are required to participate in a practice audit if they are selected randomly from the Register. Five percent (5%) of the total number of active licensed registrants will be randomly selected each year. Other Registrants may be selected by other criteria specified by the committee such as a referral from the Complaints Resolution Committee or the Registrar.

Frequency of registrant participation

Each registrant holding an active license from the OOM will participate in the Practice Audit process a minimum of once every 10 years.

Components of a Practice Audit A Practice Audit will consist of a 3-4 hour onsite visit by two Auditors which will include:

  • a chart review
  • situation based questions
  • eye glasses questions
  • contact lens questions
  • an inspection of the premises
  • applicable data collection

Referrals for a Practice Audit from the OOM Complaints Resolution Committee or the Registrar – If the Practice Audit Program has been requested by the Complaints Resolution Committee or the Registrar to perform an audit because of particular concerns that have been identified regarding a registrants practice, the Practice Auditors will be provided with the specific areas of the registrant’s practice which are to be audited . The registrant will be notified of the focus of the audit and will be required to pay fifty percent (50%) of the cost of the audit capped at a maximum of $200.00.

Registrant Notification Registrants who have been randomly selected by the OOM or who have been referred to the Practice Audit Program to be audited for a specific reason by the Complaints Resolution Committee or the Registrar will be notified by a Registered Letter from the OOM.

Scheduling and Preparation for the Audit:

  • Within 5 days of receipt of the Registered letter the registrant will be contacted by the Practice Auditors to coordinate dates and time with the registrant for the audit.
  • The registrant must be off duty when the audit takes place
  • A quiet room in the dispensary should be selected by the registrant for the audit.
  • The Audit will be scheduled within 60 days of the registrant having been notified at a mutually agreeable date, time and location.
  • Within 30 days of receipt of the Registered Letter the registrant and the auditor must confirm that there is no conflict of interest
  • The registrant will select ten(10) client records for review, five (5) of which will be chosen by the auditors for review

Practice Audit Tool An onsite assessment tool will be used in a face to face either in person or through a web- based mechanism.

Taking Notes During the Practice Audit, Preparing and submitting the Audit Report In order to ensure the confidentiality and security of the information collected onsite during the audit and the information in the audit report, the auditors will only use the Opticians of Manitoba’s laptop designated for the sole use of the Audit Program and housed in the OOM office. All the audit documents (chart review, interview questions, premises inspection) will be kept on the laptop desktop.

When an audit is scheduled the OOM will

  • be notified by the auditors of the date and location of the audit
  • courier the designated laptop to the auditors prior to the date of the audit

The auditors will:

  • bring the designated laptop to the audit
  • will prepare and save the audit report on the laptop and courier the laptop to the OOM Registrar within 14 days of completion of the audit
  • not print the audit report or send it to anyone by email

The Registrar will:

  • send a copy of the written report by Registered mail to the registrant within four (4) weeks of the date of the audit if no immediate risks to the public have been reported by the Auditors.

Reporting Areas of Immediate Concern that Pose a Risk to the Public The Auditors will notify the Registrar immediately if during the audit they become aware of any issues that may pose a risk to the public

Actions to be Taken by the Registrar and Quality Assurance Committee (QA) on Immediate Areas of Concern Reported to Pose a Risk to the Public

The Registrar will schedule an immediate meeting of the Quality Assurance Committee
if areas of potential risk to the public have been reported by the Auditors

The Quality Assurance Committee will:

  • decide on any immediate appropriate action to be taken to eliminate any risk to the public if concerns regarding risk have been reported by the auditors
  • actions which may be taken include imposing a term or condition or limitation on the registrant’s license and /or specifying an education plan for the member to complete to rectify the behaviour before the condition is lifted.

Registrant’s Response to the Audit Report

  • The registrant will have 14 days following receipt of the report if they wish to submit a written response to the Quality Assurance Committee. The response may include any information or details that the registrant would like the QA Committee to have including any personal learning needs that the registrant has identified.
  • The QA Committee will consider the registrant’s Audit report and written submission if the registrant has chosen to submit one and will provide the registrant with a confirmation of their strengths and weaknesses within 30 days of receiving the documents

Decisions of the Quality Assurance Committee The committee may decide to;

  • Make no recommendations, in which case the report will be accepted as written and the audit process will be terminated
  • Make recommendations for the registrant to correct any deficiencies noted in the audit report and to pursue the registrants identified learning needs using the audit report to develop goals and a plan to address the learning needs and deficiencies identified during the audit.
  • If after reviewing the audit report , the QA Committee identifies that the registrants has demonstrated insufficient knowledge, skill or judgement, they may direct the registrant to complete specific learning activities
  • If the QA Committee identifies an immediate risk to the public, they may put terms, limits or conditions on the registrant’s license.

Practice Support Registrants will be supported throughout the process from the initial assessment to implementation of a plan to address any deficiencies noted during the Practice Audit process.

Registrants who have been identified during the Practice Audit as requiring enhancement of knowledge, judgement, skills and registrants and who have requested assistance in their response to their audit report will be provided with practice support and direction by the OOM. This support may include specified continuing education and or remediation completed independently or in combination with support provided by the OOM. Registrants will however be responsible for the costs of any continuing education or remediation specified by the OOM.

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