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Facility Director - Accreditation - Definition and Responsibilities

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Policy Statement

Published: July 2022


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 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 standards established by the College Council. 


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 standards as established by the Council under section 8 of the Act. 


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 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 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:   

  1. A change to the name of the veterinary facility. 

  1. A change in the type of species treated in or from the facility. 

  1. A change in the scope of veterinary services offered in or from the facility. 

  1. The relocation of the veterinary facility or of a stationary element of a facility with a mobile element. 

  1. A change in the identity of the facility director. 

  1. 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 veterinarians exercise control over or influence the clinical and professional aspects of the provision of services through the facility and that they maintain 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) of their team. 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 standards, the responsibilities of a facility director in relation to facility accreditation include, but are not limited to: 

  1. ensuring the name of the facility director and their contact information are clearly and publicly displayed at the veterinary facility; 

  1. making all necessary applications for facility accreditation in a timely manner; 

  1. paying the facility accreditation fee and/or any other fees set out in the College by-laws; 

  1. facilitating the scheduling of an inspection and ensuring all staff and licensed veterinarians at the facility fully cooperate with and respond to all reasonable requests of an inspector; 

  1. being onsite and participating as needed in inspections; 

  1. promptly providing any records when requested by the College; 

  1. undertaking to correct any deficiencies noted at the time of an inspection within the specified timeline provided; 

  1. complying with any terms, conditions and limitations placed on the certificate of accreditation by the Accreditation Committee; and 

  1. ensuring that all veterinarians employed in the veterinary facility are appropriately licensed. 

Registrar’s Authority 

Should the College receive information that indicates that a veterinary facility is not meeting its obligations with respect to the certificate of accreditation, the Registrar can cause an inspection of a veterinary facility to determine if the facility is being operated under and in accordance with a certificate of accreditation and that the facility director is ensuring that the facility is meeting the regulations and the standards established by the Council under section 8 of the Act. (O.Reg.1093 section 17 and 50). In certain cases, the College may take steps to propose to revoke the facility’s certificate of accreditation. (Veterinarians Act, section 18 and 36) 

The College may also, in certain circumstances, begin an investigation into potential professional misconduct on the part of the facility director. 

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)  

College publications contain practice parameters and standards which should be considered by all Ontario veterinarians in the care of their patients and in the practice of the profession. College publications are developed in consultation with the profession and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained. The College encourages you to refer to the website ( to ensure you are referring to the most recent version of any document.