Skip to content

2021 CPMF Highlights

Launched in 2020, the Ministry requires all health regulatory Colleges to complete and report on the College Performance Measurement Framework (CPMF) on an annual basis. The purpose of the CPMF is to assess how well Colleges are executing their mandate to act in the public interest.

In the inaugural 2020 College CPMF submission, there were a total of 38 standards in which there were 6 measures where the College marked as “partially met” or “not met” and 5 measures have now moved to “met the requirement" showing our commitment to improvement.

The second iteration of the CPMF was refined based on feedback from Colleges, the public and experts resulting in the addition of three new focus areas: Diversity, Equity and Inclusion, Risk Management, and Use of Technology. Colleges are being asked to report on the new measures and Evidence, as well as report back on improvement plans identified in 2020 and report on any changes in comparison to 2021.

For the 2021 report, the College was asked to report on 50 measures.  COTO was able to demonstrate that it met 47 measures, partially met 2 measures, and only having 1 measure it did not meet.

The following three measures were identified as either being partially or having not met the standard:

Domain 1: Governance

  • Measure/Evidence: 3.3 (a) The DEI plan is reflected in the Council’s strategic planning activities and appropriately resourced with the organization to support relevant. (See report page: 25)

    Partially met

  • Measure/Evidence: 3.3 (b) The College conducts Equity Impact Assessments to ensure that decisions are fair and that a policy, or program, or process is not discriminatory. (See report page: 25)

    Not met

    Action Item: 
    While the College has accomplished several measures related to DEI in the 2021 reporting year, it will work to create a formal DEI plan. As well, the College will look to also create an Equity Impact Assessment tool to ensure that our policies, practices, and decision-making processes are fair and do not present barriers to any protected group.


Domain 6: Suitability to Practice

  • Measure/Evidence: 13.1(a) The College’s policy outlining consistent criteria for disclosure and examples of general circumstances and type of information that has been shared between the College and other relevant system partners, within the legal framework, about concerns with individuals and any results. (See report page: 50)

    Partially met

    Action Item: 
    College is currently working on developing a written policy to outline the criteria for disclosing information that will be finalized in 2022.


Highlights from COTO’s 2021 CPMF report include:

Domain 1 Governance

  • Developed the Board Competency Framework as well as defining the competencies for all College Committees.
  • Meeting materials for the Board enable the public to clearly identify the public interest rationale. 
  • The College’s Board and Committees have a Code of Conduct and Conflict of interest policy that is accessible to the public.  
  • The College’s Risk Management Program is integrated into the College’s strategic planning and operations.
  • Minutes and decisions from all College board committees (Executive, Governance and Finance and Audit Committee) are transparent and posted in each board meeting package.

Domain 2 Resources

  • Our strategic plan and budget processes are closely aligned to support strong financial and resource stewardship.
  • The College regularly reviews and updates its financial reserve policy that sets out the level of reserves the
  • College needs to build and maintain to meet its legislative requirements.
  • College developed its data and technology plan to reflect how it adapts its use of technology to improve College processes to meet its mandate.

Domain 3 System Partners

  • The College has demonstrated that it actively engages with other health regulatory colleges and system partners to support and strengthen alignment of practice expectations and quality improvement.
  • The College maintains cooperative and collaborative relationships to ensure it is responsive to changing public/societal expectations.
  • The College engages extensively with a broad range of partners through the formation of Equity and Indigenous panels which was instrumental in the development of the Culture, Equity and Justice practice document.  

Domain 4 Information Management

  • IT security at the College is regularly audited.
  • The College has protocols in place for handling cybersecurity issues and accidental or unauthorized disclosure of information.  This includes a designated staff Privacy Officer to address confidential and privacy breaches.  
Domain 5 Regulatory Policies
  • College standards of practice, guidelines and policies are reviewed regularly to determine whether they are appropriate or require revisions.  A review is expedited if there are changes in the occupational therapy practice landscape, in legislation or in changing public expectations.
  • Highlighted College work where DEI principles and values are reflected include revising the College’s Code of Ethics for registrants to reflect DEI commitments and updating the College’s Code of Conduct for
  • Directors and Committee members by adding provisions that address diversity and inclusion; and implementing the Board Competency Framework that incorporates the diverse perspectives and backgrounds.

Domain 6 Suitability to Practice

  • Registration policies are routinely reviewed to ensure best their continued relevance and necessity. 
  • College piloted a new risk-based Quality Assurance Program.
  • The College responds to 100% of complain enquiries from the public within 5 business days, with follow-up timelines are necessary.
  • Different stages of the complaints process and all relevant supports available to complainants are clearly communicated and set out on the College’s website and are communicated directly to complainants. 
  • All parties to a complaint and discipline process are kept up to date on the progress of their case, and complainants are supported to participate effectively in the process. 

Domain 7 Measurement, Reporting and Improvement

  • The College provides a quarterly report to the Board and all information collected and reported on is related to the College’s strategic priorities.