The undertaking with the College is the facility director’s agreement to accept the obligations, as outlined in the Policy Statement: Facility Director - Accreditation, for the oversight of the accreditation of the veterinary facility.

This occurs in one of two ways:
1. when the facility director applies for inspection of the facility in the Professional Practice Portal or
2. by completing the form Notification of Change of Facility Director of an Accredited Facility.

The facility director must be engaged in the practice of veterinary medicine conducted in or from the facility.

• A facility director is expected to be employed or contracted at the accredited facility they oversee, and to practice veterinary medicine onsite at the accredited facility not less than four days a month. There is flexibility when these days occur, for example, one day a week, two days every other week, or four days in one week.
• When they are not onsite, the facility director must be available to be contacted during operating hours and respond within a reasonable timeframe to provide oversight, and this may be provided remotely (e.g., by phone).
• Short term absences (e.g. vacations) may be covered by another responsible veterinarian employed or contracted at the facility.

The facility director must be present at the veterinary facility to discuss the outcome of the accreditation inspection with the College’s inspector.

A veterinarian has a conflict of interest if a non-veterinarian employer or contractor exercises control or influence over clinical or professional aspects of the veterinarian’s work. If this occurs, the veterinarian must manage the conflict of interest. In their undertaking with the College, the facility director undertakes to ensure only licensed veterinarians will have responsibility for and control over all of the clinical and professional aspects of the provision of services through the facility and that they maintain the standards of practice of the profession.

For more information about conflict of interest, see the Guide to the Professional Practice Standard: Conflicts of Interest in the Practice of Veterinary Medicine. 

If the facility director is not onsite at the facility and engaged in the practice of veterinary medicine in or from the facility for at least four days a month, or they are not available to be contacted during operating hours and respond within a reasonable timeframe to provide oversight, it is necessary to arrange for another licensed veterinarian to assume the role. This requires a form to be submitted to the College for a change of facility director.

If the absence is temporary and the previous facility director returns and fulfills these requirements, a form can be submitted to the College to change the facility director back to the previous facility director

 

The process for assigning responsibilities is between the facility director and their colleague(s) and they can decide whether it requires something in writing. The College does not require anything to be submitted and any process that is used to assign responsibilities is between the facility director and their colleague(s).

The facility director can assign some of their responsibilities to other licensed veterinarians in the practice, but it is not the intention that they would assign all of them. If it is the intention that another licensed veterinarian take on the primary role and responsibilities for meeting the facility standards, then the College must be notified immediately of a change of facility director. 

The facility director can assign some responsibilities to capable members of their team, who are not licensed veterinarians, to assist them with meeting the facility standards. The facility director remains responsible for any tasks they assign to their team members.

The licensed veterinarian who is listed as the current facility director would need to  go to the College website and fill out the form Notification of Change of Facility Director of an Accredited Facility. This will not prompt an inspection and there is no fee.

 

If someone has a concern about a veterinary facility not complying with the accreditation standards, this concern would not be investigated through the complaints process. If a concern is brought to the College’s attention, the Registrar may cause an inspection of the facility to determine if the facility is being operated under and in accordance with the certificate of accreditation. The inspection report would be reviewed, and any action the College takes will impact the certificate of accreditation, not the Facility Director’s licence. It is rare for the College to receive serious concerns about a facility. In exceptional circumstances, an inspector may identify serious concerns about the conduct of the Facility Director, and these may be brought to the Registrar for review. This only happens if public safety is a significant concern.

The College expects that facility directors are following all laws that apply to the facility. This includes the College’s legislative requirements and facility standards. In addition, there are requirements under federal legislation, such as the Controlled Drugs and Substances Act. It includes provincial legislation related to x-ray machines under the Ministry of Labour, Radiation Protection Services. Municipal standards include building codes and permits and proper disposal of hazardous materials. 

When they are not onsite, a facility director must be available to be contacted during operating hours and respond within a reasonable timeframe to provide oversight, and this may be provided remotely (i.e., by phone). If the facility director is not available to be contacted during a short-term absence, such as a vacation, coverage by another responsible veterinarian who is employed or contracted at the accredited facility is permitted.

If any of the following events occur, the College must be immediately notified:

• Any change to the name of the veterinary facility.
• Any change in the type of species treated in or from the facility.
• Any 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.
• Any change in the identity of the facility director.
• The facility no longer has any members who would satisfy the requirements set out in paragraph 3 of subsection 11 (2).

It is the responsibility of the holder of the certificate of accreditation to immediately inform the College of any of the above events. If there is a change in the identity of the facility director, or the facility no longer has a facility director, the holder of the certificate must inform the College. 

 

The facility director must include in their application for the issuance or renewal of a certificate of accreditation a written attestation from the owners or partners, as the case may be, that the facility director is authorized to be the facility director and is authorized to provide the undertaking for the oversight of the accreditation of the veterinary facility. 

The role of the facility director is very specific in terms of the responsibilities and accountabilities to the College with respect to facility accreditation.  The reason for displaying the name of the facility director is to assist clients and staff to know which veterinarian is responsible for ensuring that the facility meets the expected standards of accreditation.  The person taking on this role may not necessarily be the person in charge of other aspects of the practice.  How this is displayed in the practice is at the discretion of the facility director.