Policy Statement
Published: July 2022
Revised: April 2025
Introduction
In Ontario, a veterinarian providing clinical care to animals is required to work from an accredited facility. The profession, through Facility Accreditation, ensures access to quality veterinary care in a safe and professional environment through regular inspections of veterinary facilities conducted by trained inspectors.
The accreditation process supports public confidence in the veterinary facility and enhances the quality of veterinary care by requiring that veterinarians review their facilities regularly to ensure they continually meet facility accreditation standards for quality and safety.
All accredited veterinary facilities are under the oversight of a licensed veterinarian who is the facility director. Facility directors are responsible for ensuring that veterinary facilities are operated in accordance with the facility accreditation standards established by the College Council.
Purpose
This policy statement has been developed to clarify the obligations and responsibilities of a facility director with respect to ensuring that an accredited veterinary facility is operating in accordance with the Veterinarians Act, its Regulations, and facility accreditation standards as established by the Council under section 8 of the Act.
Definitions
Accredited Veterinary Facility: A veterinary facility that has been granted a certificate of accreditation by the College which signifies that the veterinary facility is operating in accordance with facility accreditation standards.
Facility Director: The licensed veterinarian who applies for the certificate(s) of accreditation for a veterinary facility and declares to the College that they are responsible for the facility. The facility director may be an owner of the veterinary facility or a partner in the practice conducted in or from the facility, or a licensed veterinarian designated by the owner(s) or partner(s). The facility director must be engaged in the practice of veterinary medicine conducted in or from the facility.
Holder of a Certificate of Accreditation: The holder of a certificate of accreditation is the owner(s) of the veterinary facility or the partners in the practice conducted in or from the facility.
Facility Director Accountability
The facility director signs an undertaking which is submitted to the College and by doing so, the facility director is accepting the obligations, as outlined in this document, for the oversight of the accreditation of the veterinary facility.
Under a facility director’s oversight, a facility is expected to meet all relevant facility accreditation standards for the duration of its certificate of accreditation.
Responsibilities of Holder of a Certificate of Accreditation
The holder of a certificate of accreditation must ensure 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.
The holder of a certificate of accreditation is required to immediately notify the College, in writing, if any of the following events occur:
A change to the name of the veterinary facility.
A change in the type of species treated in or from the facility.
A change in the scope of veterinary services offered in or from the facility.
The relocation of the veterinary facility or of a stationary element of a facility with a mobile element.
A change in the identity of the facility director.
The facility no longer has any licensed veterinarian who would satisfy the requirements of a facility director as set out in paragraph 3 of subsection 11 (2) of Regulation 1093.
The College expects that the facility director will assist the holder of the certificate of accreditation in fulfilling these responsibilities.
Responsibilities of the Facility Director
The facility director will ensure only licensed members will have responsibility for and exercise control over all of the clinical and professional aspects of the provision of services through the facility including maintaining the standards of practice of the profession.
Where the facility director is unable to fulfil this role or in times of absence, (e.g., vacation), there must be an arrangement for another veterinarian to assume this role.
The facility director can delegate some responsibilities to capable licensed veterinarian(s) and/or veterinary team members. Having a facility accreditation team will help ensure that everyone is aware of how the veterinary facility is meeting the College’s standards. Team involvement also encourages strong communication and collaboration throughout the accreditation process.
The facility director must be present at the veterinary facility to discuss the outcome of the accreditation inspection with the College’s inspector.
In addition to any other duty set out in the Act, Regulations and facility accreditation standards, the responsibilities of a facility director in relation to facility accreditation include, but are not limited to:
ensuring the name of the facility director and their contact information are clearly and publicly displayed at the veterinary facility;
making all necessary applications for facility accreditation in a timely manner;
paying the facility accreditation fee and/or any other fees set out in the College by-laws;
facilitating the scheduling of an inspection and ensuring all veterinary team members and licensed veterinarians at the facility fully cooperate with and respond to all reasonable requests of an inspector;
being onsite and participating as needed in inspections;
promptly providing any records when requested by the College;
undertaking to correct any deficiencies noted at the time of an inspection within the specified timeline provided;
complying with any terms, conditions and limitations placed on the certificate of accreditation by the Accreditation Committee; and
ensuring that all veterinarians employed in the veterinary facility are appropriately licensed.
Facility Director Ceases to meet Accreditation Standards for the Certificate of Accreditation
Should the College receive information that indicates that a veterinary facility director (inclusive of the holder of the certificate of accreditation, or the veterinary facility) has ceased to meet the qualifications, requirements and standards under the Act for a certificate of accreditation, the Registrar can cause an inspection of the veterinary facility (O.Reg.1093 section 17 and 50).
The Registrar may refer the certificate of accreditation to the Accreditation Committee for a hearing if the Registrar is of the opinion that there are reasonable grounds to believe that,
- The holder of the certificate of accreditation, the veterinary facility director or the veterinary facility in respect of which the certificate of accreditation was issued has ceased to meet the qualifications, requirements and standards under the Act,
- The veterinary facility in respect of which the certificate of accreditation was issued, is being used, or has been used in contravention of a term, condition or limitation of the certificate of accreditation, or
- The veterinary facility in respect of which the certificate of accreditation was issued is being used, or has been used as a veterinary facility of a class other than the class for which the certificate of accreditation was issued or renewed.
After holding a hearing, the Accreditation Committee may direct the Registrar to,
- Revoke the certificate of accreditation
- Suspend the certificate of accreditation pending the demonstration, in such manner as the Accreditation Committee specifies, of compliance with such standards as are specified by the Accreditation Committee
- Change the class of veterinary facility
- Impose such new or further terms, conditions and limitations on the certification of accreditation as are specified by the Accreditation Committee, or
- Take no further action.
Legislative Authority
Veterinarians Act, R.S.O. 1990, c. V.3, s. 15, 18 and 36
R.R.O 1990, Reg, 1093: General, s. 10-15, 17, and 50 (Veterinarians Act)