Three-Year Review and Approval Process

How does my organization become a prescribed entity or prescribed person?

How does my organization become a prescribed entity or prescribed person?
Any organization interested in being prescribed as an entity or person should contact the ministry responsible for the legislation.

An organization must be prescribed under the law before they can have their practices and procedures reviewed and approved by the IPC.

How does my organization become a prescribed organization or prescribed unit of the Ministry of Health?

How does my organization become a prescribed organization or prescribed unit of the Ministry of Health?
The Ministry of Health specifies prescribed organizations and prescribed units of the ministry. Contact the ministry for more information.

What happens during the initial review?

What happens during the initial review?
The first time the IPC reviews and approves the practices and procedures of a prescribed entity, person, organization or unit of the Ministry of Health, we review all of the relevant policies, practices and procedures of the organization. Our manuals set out the required content for the policies, practices, and procedures.

The IPC may schedule an on-site visit to review physical security measures. We may also specify actions that must be taken prior to our approval of an organization’s practices and procedures.

Once the organization has taken all necessary actions and the IPC has granted approval, we prepare a report that summarizes the review. The IPC and the prescribed entity or person will make the following available on our websites:

  • the IPC’s report
  • the IPC’s letter of approval

Where can I find the manual that sets out the requirements for review and approval?

Where can I find the manual that sets out the requirements for review and approval?

The IPC issues manuals for the review and approval of prescribed entities, persons, organizations, and units of the Ministry of Health. Each organization is expected to meet the requirements of the manual.

What is involved in subsequent reviews?

What is involved in subsequent reviews?
Two years from the date of the initial approval, organizations that are prescribed under PHIPA, the Coroners Act, or the CYFSA must submit a detailed written report of their policies and procedures, together with a sworn affidavit signed by the head of the organization. To allow sufficient time for review, organizations must submit these materials one year before the next approval date.

After we have completed the review, we send a letter indicating whether the policies and procedures are approved.

Once the IPC has granted approval, the IPC and the prescribed entity or person will make the following publicly available:

  • the report of the prescribed entity, person, organization or unit of the Ministry of Health
  • the IPC’s letter of approval
  • the sworn affidavit signed by the head of the organization

The sworn affidavit must be signed by the head of the organization because they are ultimately accountable for ensuring that the prescribed entity, person, organization, or unit of ministry complies with the law. By signing the affidavit, the head of the organization confirms that the practices and procedures of the organization comply with both the law and the requirements of the manual.

What happens if the practices and procedures are not approved?

What happens if the practices and procedures are not approved?
A person or organization may not continue to operate under its authorities as a prescribed entity, person, organization or unit of the Ministry of Health unless it has submitted a detailed written report and accompanying sworn affidavit to the IPC and we have provided written confirmation that it continues to meet the requirements.

Do all of the three-year reviews and approvals occur at the same time?

Do all of the three-year reviews and approvals occur at the same time?

The IPC tries to conduct all three-year reviews and approvals at the same time. If an organization receives approval in an intermediate year, the approval may be granted for a period shorter than three years to ensure the next review falls within the same period as the other three-year reviews and approvals.

Where can I find documentation related to previous reviews and approvals?

Where can I find documentation related to previous reviews and approvals?
The reports, letters of approval, and sworn affidavits for every review and approval are publicly available.