Public consultation: Amendments to the Accredited Facilities Bylaw and The Affairs of the College Bylaw
Proposed amendments to the Accredited Facilities Bylaw
Proposed amendments to the Affairs of the College Bylaw
Proposed amendments to the Accredited Facilities Bylaw
CPSM requests feedback from the public, registrants, regulated health professionals, and other interest-holders on two proposed amendments to the Accredited Facilities Bylaw.
Background
The Accredited Facilities Bylaw establishes standards for facilities, their professional and technical personnel, equipment, space and safety and procedures of Diagnostic Facilities and Non-Hospital Medical or Surgical Facilities in Manitoba (NHMSF). The Program Review Committee (PRC) is the oversight governing body of these facilities, approving and recommending applications for accreditation, and monitoring compliance. The PRC is recommending eight proposed amendments to the Bylaw (one affecting Diagnostic Facilities and seven affecting NHMSF).
Proposed amendments
|
Change
|
Proposed amendment: |
|
1. Definition of “diagnostic imaging facility” to include echocardiography.
Echocardiography is a modality of ultrasound with a subspecialty in cardiac care that will now require accreditation. Shared Health, Manitoba Health, and MANQAP identified the omission of echocardiography from the definition as a gap in the scope of imaging techniques covered by the Bylaw. |
Section 1.1.6 - “diagnostic imaging facility” means a place where imaging techniques are used for diagnostic purposes including radiography, ultrasound (including echocardiography), computed tomography, magnetic resonance imaging, fluoroscopy, mammography or nuclear medicine. |
|
2. Definition of “oral sedation” for Non-Hospital Medical or Surgical Facilities.
The definition is amended to clarify that it applies to procedural oral sedation given before a procedure. |
Section 12.1 - “procedural oral sedation” means an altered state or depressed state of awareness or perception of pain brought about by pharmacologic agents given orally before a procedure under supervision and |
|
3. Definition of “procedural sedation” for Non-Hospital Medical or Surgical Facilities. The definition of “procedural sedation” is amended to add inhalation agents. |
Section 12.1 - “procedural sedation” means an altered or depressed state of awareness or perception of pain brought about by pharmacologic agents and which is accompanied by varying degrees of depression of respiration and protective reflexes in which verbal contact with the patient can be maintained, and i. includes, but is not limited to, the use of any IV, ii. requires the monitoring of vital signs, but does not include the use of oral pre-medication alone or in combination with local anaesthesia. No distinction is made between light and deep procedural sedation for credentialing or monitoring purposes.
|
|
4. Procedures requiring accreditation – diagnostic cystoscopies using disposable equipment.
The amendment will exclude the requirement that diagnostic cystoscopies using disposable equipment be performed in an accredited facility. |
Section 13.3.3.ii flexible endoscopic evaluation of: 13.3.3.ii.a the gastrointestinal tract 13.3.3.ii.b the genitourinary tract- this does not include diagnostic cystoscopy using disposable equipment;
|
|
5. Procedures requiring accreditation – ketamine administration.
The amendment will require that ketamine administered outside of a hospital can only be administered in accordance with the Accredited Facilities Bylaw. However, ketamine administered in the context of palliative care or topical preparations (creams and ointments) is excluded from this requirement. |
13.3.3.i.a. excluding topical preparations including creams, ointments, etc. 13.3.3.i.b. excluding ketamine administered in the context of palliative care.
|
|
6. Procedures requiring accreditation – Sleep Medicine Diagnostics.
The amendment will require Sleep Medicine Diagnostics procedures performed outside of a hospital to be performed in an accredited facility. |
Adding section 13.3.3. xiii Sleep Medicine Diagnostics. |
|
7. Clarifying a responsible adult is required for discharge from Non-Hospital Medical or Surgical Facilities. |
23.1.3 A patient who receives general anaesthesia or procedural sedation should only leave the facility in the care of a |
|
8. Reporting adverse patient outcomes. |
25.4.1.iii unexpected admission to hospital and/or presenting to an Emergency Department or Urgent Care within 10 days of a procedure performed. |
View the draft amendments to the bylaw here.
Proposed amendments to The Affairs of the College Bylaw
Background
CPSM Council is actively taking steps to improve its functionality and accountability.
CPSM’s Governance Policy and The Affairs of the College Bylaw set out the duties, responsibilities and duty of care for Council members (councillors). The Governance Policy contains a Code of Conduct designed to promote a high-performing professional structure for Councillors to carry out their duties and responsibilities.
At its June 24, 2026 meeting, Council updated the Code of Conduct (see section 1.2 of the Governance Policy) to improve clarity of language and to address requirements for regular attendance, self-assessment, peer and Council assessment, continuing education, annual affirmation, and non-compliance.
CPSM is proposing two amendments to The Affairs of the College Bylaw (Bylaw) to complement these improvements.
These amendments only impact Council and Council committee members.
Proposed amendments
Section 36 amendment
Section 36 of the Bylaw contains provisions for when a councillor automatically ceases to hold office. Most of the provisions are certain, such as resignation and death. However, the provision related to absence is unclear as to how and when a councillor ceases to hold office because of their absences.
Proposed amendments to the Code of Conduct specify how non-compliance (including attendance failures) are dealt with:
1.2.11 Response to non-compliance, including attendance failures
Where a Councillor or Committee member fails to comply with this Code, including persistent failure to meet attendance or participation expectations, the matter may be addressed using a graduated and fair process, which may include:
- Informal discussion or coaching by the Chair;
- Formal review by the appropriate Council body;
- Restrictions on participation in Council or Committee work;
- Censure; and,
- Any further steps available under CPSM’s bylaws, policies, or applicable legislation, including potential loss of office.
Accordingly, CPSM proposes to amend section 36 to remove the provision related to attendance so that it can be addressed by the Code of Conduct (a breach of which can ultimately lead to removal from Council).
Section 36.1 amendment
Section 36 also rightfully contains a provision that automatically ceases a councillor holding office when they are “censured pursuant to section 102 of the RHPA or an Inquiry Panel makes a finding against the registrant pursuant to section 124 of the RHPA.”
What is missing from the Bylaw is direction on the status of a councillor in between charges being laid and a finding against them.
CPSM proposes the following amendments to the Bylaw to balance procedural fairness, presumption of innocence with public confidence in CPSM’s governance and ensuring the integrity of Council’s decisions:
36.1 Suspension from Council
36.1.1 Application
This section does not apply to public representatives appointed by the Minister or Council pursuant to sections 30 and 31.
36.1.2 Voluntary withdrawal
Where a Councillor:
-
- has been charged with professional misconduct under The Regulated Health Professions Act, or
- is the subject of an investigation by the Investigation Committee,
The President may request that the Councillor voluntarily withdraw from participation as a member of Council pending the resolution of the matter.
36.1.3 Authority to suspend
Despite section 36, the Council may, by resolution passed at a duly convened meeting, suspend a Councillor from office temporarily if:
a. the Councillor has been charged with professional misconduct; or
b. the Investigation Committee has appointed an investigator to investigate the Councillor’s conduct.
36.1.4 Purpose and nature of suspension
A suspension under this section is an administrative and precautionary measure only, intended to:
· protect public confidence in CPSM’s governance; and
· ensure the integrity of Council decision‑making.
A suspension does not constitute a finding of professional misconduct and does not give rise to any presumption regarding the outcome of the investigation or proceedings.
36.1.5 Procedural fairness
The Council shall not suspend a Councillor unless:
a. the Councillor has been given written notice of the proposed suspension and the reasons for it sufficiently in advance of the meeting at which the matter is to be considered; and
b. the Councillor has been given the opportunity, prior to the meeting, to submit a written statement setting out reasons why the proposed suspension should not be imposed.
36.1.6 Effect of suspension
A Councillor who is suspended under this section:
a. is not entitled to attend Council or committee meetings;
b. is not entitled to receive materials or information circulated to Council or its committees, except as required for procedural fairness or by law; and
c. is suspended from the exercise of any powers, duties, or functions of a Councillor for the duration of the suspension, and during that period is not counted as a sitting Councillor for quorum or other governance administration purposes. For clarity, a suspension under this section does not extend or renew the Councillor’s term of office or alter the date on which the Councillor’s term would otherwise end.
36.1.7 Duration and review
A suspension continues until:
a. the Council resolves to lift the suspension;
b. the regulatory matter giving rise to the suspension is resolved; or
c. the Councillor otherwise ceases to hold office under section 36.
The Council may review the suspension from time to time and may maintain, vary, or terminate it by resolution.
36.1.8 Relationship to section 36
Nothing in this section limits or replaces the application of section 36. If a Councillor becomes subject to censure or automatic loss of office under section 36, section 36 applies notwithstanding any suspension under this section.
View the Draft Affairs of the College Bylaw amendments
We encourage you to submit your input on the proposed changes to these two bylaws.
You can submit your feedback by:
- Email to: CPSMconsultation@cpsm.mb.ca
- Mail to:
The College of Physicians & Surgeons of Manitoba
1000-1661 Portage Avenue
Winnipeg, MB R3J 3T7
The deadline for feedback is August 27, 2026 at 11:59 p.m. CST.