PRACTICE MANAGEMENT

Before You Start

The Ontario Medical Association's Practice Management & Advisory Services advises those General Surgeon members who are interested in starting out on their own to consider 10 things before setting up a practice:

1. What are your personal and professional goals? Academic, partners, group or solo?
2. What is your ideal office location and design?
3. Have you obtained all relevant licences/memberships (e.g., CPSO,
   OMA, OHIP Billing Number, FRCSC, hospital privileges, etc.)?
4. Do you require financing? Have you spoken to a financial advisor?
5. Have you determined your insurance needs? You’ll require malpractice
   insurance (contact the Canadian Medical Protective Association),
   business and personal insurance. OMA Insurance is an excellent
   source for more information (contact: info@OMAinsurance.com).
6. Have you determined how many staff you will need to run an effective practice?
7. Have you selected professional advisors (e.g. accountant, lawyers, etc.)?
8. Have you thought about the medical office systems you will require (e.g. filing systemor electronicmedical record system, telephone system/ service provider, accounting/billing system, etc.)?
9. Will you lease or purchase medical supplies, equipment and furniture (e.g. exam beds, diagnostic equipment, etc.)?
10. Have you established a source(s) for office supplies, equipment and furniture (e.g. prescription pads, appointment/ business cards, letterhead, desks, waiting roomchairs, etc.)?

Sources: OMA Review - Practice Management (2009); OMA Practice Management & Advisory Services; RCPSC Entering Professional Practice .

Office Space

Location. Location. Location. The community you choose should cater to a thriving medical practice as well as a content home life. Consider the following factors: demand for your (sub)specialty, demographics (age/socio-economic), availability to hospital privileges, growth potential in population, gov't incentives for community/ remote location, cost/standard of living, social life, career opportunities for other family members, schools, social/service organizations, etc.

Real Estate
Will you be buying or leasing your office space? Consider the following factors: visibility, patient access, public transit, parking, proximity to hospital, travelling time, rent per sq foot, cost of improvements, mechanical services, special equipment requirements, condition/maintenance, space required, expansion potential, room for other partners/services, etc. The OMA Practice Management Toolkit suggests not to underestimate spaced needed for future expansion, because relocation costs can be high. Narrow down to at least two properties and speak to other tenants and ask for references. Prepare a list of requirements before asking the landlord to provide a proposal/prices based on incorporating your needs. The lease should include all aspects of the "Offer to Lease", so be sure to ask your lawyer to review it and negotiate any amendments required. All details should be guaranteed in writing and incorporated in the lease. Be sure to figure out the cost of improvements before you decide how to finance them. Contact your bank manager and arrange for financing; bring your business plan with you. Borrow only what you need - projected for the first year for start up expenses.

Office Equipment
You will need the basics: computer, photocopier, fax, printer, refrigerator, file cabinets, clinical cabinets, desks, chairs, paper reams, business/appointment cards, prescription pads, letterhead/envelopes, wait room chairs, coffe table, reading materials, ...

Clinical Equipment
You should start with the exam table(s), swivel stool(s), exam lights, utility table(s), gloves, clinical instruments, waste cans, disinfectant, procedure trays, diagnostic equipment, wound care products, etc.

Public Health Ontario: Infection Prevention and Control for Clinical Office Practice (rev.2015) - download
Public Health Ontario: Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices In All Health Care Settings, 3rd edition (2013) - download
Public Health Ontario: Checklist for Infection Prevention and Control (IPAC) CORE Elements in Clinical Office Practice - download
Public Health Ontario: Routine Practices and Additional Precautions In All Health Care Settings, 3rd ed. (PIDAC, 2012) - download

Software
See our Practice Management - Technology page.

Sources: OMA Starting a Practice - A Guide for New Physicians.

Insurance

Malpractice Insurance:
CMPA (Canadian Medical Protective Association)

Business/Personal Insurance:
OMA Insurance: Asterisk
The OMA provides the services of non-commissioned, licensed insurance advisors who will sit down with you to review your individual and family needs, analyze your current policies, and make objective recommendations.

Business Insurance:
MD Financial Services: https://mdm.ca/wealth-management/insurance/

Financial & Estate Planning

Before you begin, you might consider obtaining the services of an accountant, financial planner, corporate lawyer, employer lawyer, real-estate lawyer/leasing agent, and possibly a business advisor/consultant.

Estate Planning: According to CMA/MD Financial Management, here is what to consider Key Factors and Considerations...
•Your Will
•Power of Attorney
•Income Tax
•Life Insurance
•Testamentary Trusts
•Estate Freezing
•Inter Vivos Trusts
•Philanthropy

The CMA/MD Financial Management advises that your will is integral to your estate and your family - even in its beginning stages. This document will ensure that: your assets are passed to the heirs of your choice, the administration of your estate is facilitated by someone you trust to do so efficiently, your income taxes payable after your death will be reduced and adequately fund their payment, it provides management of property for minors or those who lack the skill or ability to do so themselves, guardianship of minors will be delegated, and finally your affairs will be arranged in an orderly manner to minimize the burden on your family.

Financial Planning: CMA / MD Financial Management (A Strategy for Your Future) suggests you consider the following:
•Investing
•Power of Attorney
•Income Tax

Sources: MD Financial Management;

Office Staff & Training

Hiring Medical Staff:
Before you start, what is your situation? If you're with an academic hospital, an office assistant will likely be assigned to you. Are you in a group or partnership who will be sharing staff? If possible, get some tips from other receptionists, clinic managers, nurses. How were they hired? What were their job descriptions/responsibilities? According to the OMA, staff often represents 45% or more of your total practice overhead costs. If you're starting out on your own, here are a few tips:

• What do you need? - Do you need need administrative assistant and a nurse? If you can only afford one employee, perhaps seek a nurse who is willing to do multiple administrative tasks (transcribing, OHIP billing, book-keeping, appointments, phone calls, computer savvy, etc.). Bookkeeper? Maintenance? Payroll?
• Frequency - Full time or part time? Job sharing? Hourly/Salary?
• Who do you need? - He/She will need great interpersonal/organizational skills, communicate well with you/patients/other staff, and create a pleasant environment for everyone - particularly difficult patients who've been waiting awhile - multitasker with grace under fire.
• How to Find Staff - Word of mouth is a valuable resource. Ask other receptionists/nurses if they can recommend a qualified colleague. Advertise electronically with professional employment agency or local newspaper. Contact a local business school that specializes in medical receptionists. Check with your hospital's HR department.
• Who Gets an Interview? - Have a few questions ready for over the phone and then choose 3-5 candidates with whom to meet for a one-to-one interview.
• Hiring Process - You need someone for the long term, so you'll need to invest appropriate time in finding the right person for you and your office: preparing job description, advertising, interviewing, checking references, choosing performance criteria for trial period, deriving salary levels.
• When to Interview - The CMA advises that it's best to dedicate a full morning or afternoon for several interviews - not rushed in between patients or when on call.
• What Not to Ask - Provincial human rights legislation protects individuals against discrimination, so DO NOT ask about the following: family responsibilities, age, marital status, health, religion, national or ethnic origin. Only after you hire someone can you make relevant inquries for payroll requirements.
• Interview Questions/ Office Policies - The CMA has great suggestions in their Staffing and Human Resources Module. Always check references.
• Offer of Employment/Contract - A verbal agreement and handshake is not enough. Although not mandatory for office staff, a written contract that clearly states the terms and conditions of employment signed by you and the employee BEFORE the first day of work protects you both. Terms of employment include start date, hours of work, salary, overtime policy, holiday policy, sick leave provisions, etc. Clarify the probationary period (typically 3 months), performance reviews (every 2-4 wks), and the termination clause. Make sure you review the package with a employment lawyer before presenting it to the successful candidate.
• Seal the Deal - Telephone the successful candidate, get a verbal acceptance and proceed to courier the contract for their signature on 2 copies.
• Call the other inteviewees, thank them and ask to keep their resumes on file for future reference. Keep all notes and evaluations.
• Payroll - It might be worth delegating this task to a bookkeeping service. Contact the Canada Revenue Agency for a payroll kit and register to obtain a CRA business number, if you don't have one already: 1-800-959-5525, CRA payroll.

OHIP Billing Seminars for Medical Staff:
The OMA Practice Management and Advisory Services offers primary care billing seminars to medical staff, but a special request must be made for specialist billing seminars. Furthermore, there must be at least 10 medical staff in attendance, for them to come to your location. For medical staff, the full day seminar would cost approximately $200 per person. If, however, you cannot gather 10 medical staff members, you can call the OMA Economics Department for individual complimentary billing advisory over the phone (OMA members only). For more details: practicemanagement@oma.org; economics@oma.org / 1-800-268-7215.

Letting Staff Go:
See CMPA

Sources: MD Financial Management/CMA Module 15-Staffing and Human Resources; OMA Practice Management and Advisory Services.

Billing

Registering for a OHIP Billing Number

1. Billing Number: As mentioned previously, you will need to register for a billing number with the MOHLTC/OHIP. Email: ProviderRegistration.MOH@ontario.ca

Billing Seminars

1. Billing Seminars for Physicians: There are complimentary primary care billing seminars offered by the OMA Practice Management and Advisory Services. For specialist billing, however, you would have to make a special request for a seminar, and there would have to be at least 10 physicians in attendance (approx. 3 hrs). They would come to your location. If it is just yourself, however, you are encouraged to contact the OMA Economics Department for complimentary individual billing advisory (OMA members). For more details: practicemanagement@oma.org; economics@oma.org / 1-800-268-7215.
2. Billing Seminars for Medical Staff: Again, the same conditions are available for medical staff, but it costs approximately $200 per person. There would have to be at least 10 staff members in attendance and it would be a full day at your location. If, however, you cannot gather 10 medical staff members at once, you as the physician can resort to calling the OMA Economics Department for individual complimentary billing advisory over the phone. For more details: practicemanagement@oma.org; economics@oma.org / 1-800-268-7215.

Billing Process

• Refer to the OAGS Billing page

Compensation Models

• Fee-for-Service (FFS) - price of each service is listed in the OHIP Schedule of Benefits and Fees. This model is widely used by specialists and can be blended with other incentive plans or APPs.
• Salary / Capitation / Benefits - Academic situations possibly blended with specialist FFS.
• Alternative Payment/Funding Plan (APP/AFP)- This is sometimes a non-FFS, but most agreements are blended models that combine a base rate, incentive/premium payments and possibly a FFS component payment. They are contractual arrangements between the MOHLTC and a group of physicians, and may include other organizations such as hospitals/universities. Some AFPs/APPs also include funding for teaching and research. They are utilized mostly in specific communities or under-serviced specialties.
• Northern Group Funding Plan (NGFP) - A version of APP which primarily pertains to Northern Ontario groups with salary and incentives.
• Northern Specialist Alternative Payment Plan (NSAPP) - An APP on an individual basis in Northern Ontario.
• Hospital OnCall Coverage Program (HOCC) - Established only in 2000, the Program is funded and administered by the MOHLTC to facilitate the provision of after-hours on-call services at eligible acute care hospitals. The HOCC Program provides incentives to physicians for the additional burden.

Sources: MOHLTC/OHIP; OMA Practice Management (members only); UofCalgary School of Public Policy, Vol 7,Issue 11, April 2014; HFO Specialist Practice Models.

Patients & Records

Accepting New Patients
The Ontario Medical Association offers a "New to Practice Announcement Service" for its members. Please contact the OMA Member Administration Department for more details: www.oma.org / 1-800-268-7215

Communicating With Patients

• Respect each patient - Recognize a patient's vulnerability and individuality. Listen as much as you speak to get the complete picture and take time to explain without the jargon.
• Display empathy - Acknowledge what they tell you and repeat their concerns. Validate their feelings.
• Confirm comprehension - Don't confuse silence with agreement or understanding. Invite them to summarize what you just told them.
• Manage patient's expectations - Ensure the patient understands the next steps and possible outcomes.
• Address concerns and show concern - Give a patient time to tell their story. Patient satisfaction increases because of positive interactions.

Medical Records: Reasons to keep comprehensive, accurate, legible notes

• an account of the patient's medical history supports the patient-centred care
• a reference for colleagues who might cover for you in case of absence; saves time and avoids redundant investigations
• helps you prepare efficient and effective reports - saves you time
• acts as evidence in a medical record/billing audit
• comprehensive records is your best defence during disciplinary reviews by the College (or judicial system)

Electronic Medical Records (EMR)
EMRs must be strongly encrypted and routinely backed up in a physically secure environment separate from where the original data is stored. Physicians should carefully research available EMR products and services which must be capable of capturing all the pertinent personal health information and allowing the user to access patient information in an efficient manner. See Medico Legal Medical Records for more details.

Record Storage
All patient records and data must be kept in a restricted access area or locked in filing cabinets, or in the care of EMRs strongly encrypted. The CPSO advises that you keep medical records for 10 years after the last entry, or 10 years after a child patient would have reached 18 years of age. Due to the Limitations Act, however, the College recommends retaining the records for a minimum of 15 years of the last entry, as this is the allowable window during which a patient can make a legal claim. If the patient ha requested to view their records, you might want to keep those in particular a little longer. Once your obligation has been fulfilled, records can be disposed of in a secure manner such as cross-shredding. EMRs and any other back-up copies should be deleted permanently from all hard-drives or any other storage mechanisms (online). See the CPSO Policy on Medical Records for more detailed information.

Patient Records: Avoiding Medico-Legal Conflicts
See Medico Legal

Sources: OMA; Ontario Medical Review - Dec,2011; CMA Module 6 - Medical Records Management; CPSO Policy Statement - Medical Records; CPSO Module 7 - Electronic Medical Records.

Incorporation

According to various sources, the main reason for considering incorporating one's surgical practice is to reduce taxes. With respect to limiting liability, however, the Business Corporations Act of Ontario (OBCA) does not limit professional liability of physicians who practice medicine through a Medicine Professional Corporation ("MPC"), so it's a moot point and therefore only leaves financial benefits.

SHOULD I INCORPORATE?
Surgeons are highly advised to carefully review and discuss this decision with your own financial advisor and/or lawyer who are privy to your financial matters. According to the OMA, you should consider several main aspects to help you in your decision:

1. Income - Unless the tax savings that will be gained through incorporation is greater than the additional accounting, legal and registration costs that will be incurred in the process, it's likely not worth it. Ask your accountant and lawyer to provide you with estimates of initial and ongoing costs if you were to proceed with incorporation. The OMA guestimated an additional $3,000+ in additional accounting and legal fees per year.
2. Source of Income - Are you currently an employee or partner? For example, employees who incorporate as Personal Services Corporations are not qualified to claim the lower small business tax rates. And as the number of partners increase,the ability to defer more taxes decreases.
3. Shareholding - Most tax advantages from incorporating are available to one-physician shareholder corporations.
4. Residency/Financial Status - You have to be a resident Canadian and not currently in the process of bankruptcy

NEXT STEPS

1. Surgeons intending to incorporate must do so under the Ontario Business Corporations Act. With the help of your lawyer, you will need to file articles of incorporation with the Ministry of Government and Consumer Services. Before doing so, you will need to choose a name for your corporation. All Ontario medicine professional corporations must adhere to the naming format which requires all titles to include the words "Medicine Professional Corporation" or the French version "Medecine Societe Professionnelle" (not both) plus the physician's surname as it appears on the CPSO's register. A name search with http://nuans will have to be performed in order to reserve it.
2. Then, you will have to obtain what's called the Certificate of Authorization from the CPSO, which allows the corporation to practise medicine in Ontario. (see below)
3. Once your corporation is in place and CPSO's authorization has been received, you must "organize" the corporation, which entails adopting bylaws, issuing shares, appointing directors, completing an annual information Return with the MGCS, etc.

CPSO
The College of Physicians and Surgeons of Ontario (CPSO) CANNOT offer you any accounting or legal advice on whether you should incorporate your business. It is only after you have made your decision to proceed, that you may then contact the CPSO. The CPSO's role is to provide what's called a Certificate of Authorization for a Corporation to Practise Medicine in Ontario. You have to apply/renew with the CPSO each year on your anniversary date. The application for annual renewal must be accompanied by a Certificate of Status from the Ministry of Government and Consumer Services - no more than 30 days before the application renewal is submitted. The initial issuance of a certificate of authorization is $350; thereafter, a renewal fee will be $125. For more information and requirements, visit the CPSO website; Email: corporations@cpso.on.ca; Phone: 416-967-2673, ext 673 / 1-800-268-7096

Sources: OMA Incorporating a Medical Practice; CPSO Incorporation Issuance and Renewal; Ontario Medical Review Sept.2008;

Continued Professional Development & Life-long Learning

"Continuing professional development (CPD) is a priority and professional obligation for Fellows of the Royal College and other Health Care Professionals who participate in the Royal College's Maintenance of Certification (MOC) Program. The MOC Program is an educational initiative designed by the Royal College to support, enhance and promote the lifelong learning of Fellows and other Health Care Professionals and provides a framework for a variety of CPD activities." - Royal College of Physicians and Surgeons of Canada

According to the RCPSC website, new MOC cycles starting on or after January 1, 2014 require all Fellows and MOC Program participants to complete a minimum of 25 credits in each section of the MOC Program during their new 5-year MOC cycle. The requirement to complete a minimum of 40 credits each year and 400 credits over a five-year cycle are still applicable.

For more CPD/CME listings: Meetings

Source: RCPSC MOC Program

Resources

College of Physicians and Surgeons of Ontario (CPSO)
CPSO Independant Practice Certificate of Registration
The Practice Guide: Medical Professionalism and College Policies: website; Download Practice Guide
CPSO Registration Requirements
CPSO Certificate of Authorization: corporations@cpso.on.ca; Phone: 416-967-2673, ext 673 / 1-800-268-7096

MOHLTC OHIP Billing Number Registration
Healthcare Provider Registration - application for OHIP Billing Number
MOHLTC/OHIP Website
HOCC Program

Canadian Medical Protective Association
CMPA Malpractice Insurance Application

Ontario Medical Association
www.oma.org
OMA Insurance
OMA Practice Management and Advisory Services (request a billing seminar)
OMA Economics - economics@oma.org (email for billing advisory)
OMA Practice Management Quick Tips
OMA Practice Management - Q&A

Royal College of Physicians and Surgeons of Canada
www.royalcollege.ca
RCPSC MOC Program
RCPSC Entering Professional Practice