(1 of 2)
Effective May 8, 2026, Dr. Shannon Kehoe must cease to practice medicine until such time as she has a clinical supervisor approved by the College, as specified by paragraph (7) (g) of her Undertaking with the College dated May 8, 2026.
(2 of 2)
As from May 8, 2026, the following is imposed as a term, condition and limitation on the certificate of registration held by Dr. Shannon Brigid Kehoe in accordance with an undertaking and consent given by Dr. Kehoe to the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
(“Undertaking”)
of
DR. SHANNON BRIGID KEHOE
(“Dr. Kehoe”)
to
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
(the “College”)
A. PREAMBLE
(1) In this Undertaking:
“Code” means the Health Professions Procedural Code, which is Schedule 2 to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as amended;
“Discipline Tribunal” means the Ontario Physicians and Surgeons Discipline Tribunal of the College;
“ICRC” means the Inquiries, Complaints and Reports Committee of the College;
“IEP” means Individualized Education Plan;
“OHIP” means the Ontario Health Insurance Plan;
“Ontario Physicians and Surgeons Discipline Tribunal” means the Discipline Committee established under the Code;
“Practice Location” or “Practice Locations” means each and every location at which Dr. Kehoe practises, delegates, or has privileges, including, but not limited to, any hospitals, clinics, offices, and any Out-of-Hospital Premises or Independent Health Facilities with which she is affiliated, in any jurisdiction;
“Public Register” means the College’s register that is available to the public.
(2) I, Dr. Kehoe, certificate of registration number 94947, am a member of the College.
(3) I, Dr. Kehoe, acknowledge that I ceased to practise medicine effective September 26, 2024.
(4) I, Dr. Kehoe, acknowledge that the College has now approved my return to the practice of medicine.
(5) I, Dr. Kehoe, acknowledge that I am entering into this Undertaking further to my intention to re-enter the practice of family medicine.
B. UNDERTAKING
(6) I, Dr. Kehoe, undertake to abide by the provisions of this Undertaking, effective immediately.
(7) Clinical Supervision
(a) I, Dr. Kehoe, undertake to practise under the guidance of a clinical supervisor or clinical supervisors acceptable to the College (the “Clinical Supervisor” or “Clinical Supervisors”), for at least ten (10) months (“Clinical Supervision”). Clinical Supervision shall cease only upon approval from the College.
(b) I, Dr. Kehoe, undertake to remain free of any conflict of interest with the Clinical Supervisor.
(c) I, Dr. Kehoe, undertake to practise under the following terms of Clinical Supervision:
Phase 1 – Moderate Level Supervision
(i) I will practise only under Moderate Level Supervision for a minimum of four (4) months (“Moderate Level Supervision”), during which time I will act as the Most Responsible Physician (“MRP”).
(ii) During Moderate Level Supervision, my Clinical Supervisor will:
1. be immediately available onsite or by phone at all times when I am providing patient care;
2. during the first month of Moderate Level Supervision, directly observe a minimum of one half (1/2) day of my patient encounters every week;
3. for the first two (2) months of Moderate Level Supervision, meet with me at my Practice Location, or another location approved by the College, once every week;
4. following the first two (2) months of Moderate Level Supervision, meet with me at my Practice Location, or another location approved by the College, once every two (2) weeks;
5. review at least ten (10) of my patient charts at each meeting. Charts selected for review shall represent a variety of common conditions managed in a family medicine practice (see the CFPC’s Priority Topics), and shall be selected by the Clinical Supervisor;
6. discuss any concerns arising from the chart reviews and direct observation;
7. make recommendations to me for practice improvements and ongoing professional development, including in relation to my documentation and care, and inquire into my compliance with the recommendations;
8. perform any other duties, such as reviewing other documents or conducting interviews with staff or colleagues, that the Clinical Supervisor deems necessary to my Clinical Supervision; and
9. submit a written report to the College at least once after two (2) months of Moderate Level Supervision, or more frequently if the Clinical Supervisor has concerns about my standard of practice, commenting on:
(i) my management of patients;
(ii) procedures or presentations that I am competent to perform and/or assess;
(iii) procedures or presentations for which I need further education, if any;
(iv) topics reviewed with me and my success in implementing changes in practice;
(v) my review of current practice guidelines;
(vi) my quality of documentation;
(vii) my receptiveness to feedback and suggestions;
10. submit a written report to the College at least once after four (4) months of Moderate Level Supervision and every two (2) months of Moderate Level Supervision thereafter, or more frequently if the Clinical Supervisor has concerns about my standard of practice, commenting on the matters listed in (7)(c)(ii)9, and:
(i) support for my transition to Low Level Supervision.
Phase 2 – Low Level Supervision
(iii) After a minimum of four (4) months of Moderate Level Supervision, if my Clinical Supervisor recommends and the College approves a reduction in the level of supervision, in its sole discretion, I will practise only under Low Level Supervision for a minimum of six (6) months (“Low Level Supervision”).
(iv) During Low Level Supervision, my Clinical Supervisor will:
1. be available by phone or email to discuss cases, but not necessarily in real time;
2. meet with me at my Practice Location, or another location approved by the College, once every month;
3. review at least fifteen (15) of my patient charts at each meeting, selected by the Clinical Supervisor;
4. discuss any concerns arising from the chart reviews;
5. make recommendations to me for practice improvements and ongoing professional development, including in relation to my documentation and care, and inquire into my compliance with the recommendations;
6. perform any other duties, such as reviewing other documents or conducting interviews with staff or colleagues, that the Clinical Supervisor deems necessary to my Clinical Supervision; and
7. submit a written report to the College at least once after three (3) months of Low Level Supervision, or more frequently if the Clinical Supervisor has concerns about my standard of practice, commenting on:
(i) my management of patients;
(ii) procedures or presentations that I am competent to perform and/or assess;
(iii) procedures or presentations for which I need further education, if any;
(iv) topics reviewed with me and my success in implementing changes in practice;
(v) my review of current practice guidelines;
(vi) my quality of documentation;
(vii) my receptiveness to feedback and suggestions;
8. submit a written report to the College at least once after six (6) months of Low Level Supervision and every three (3) months of Low Level Supervision thereafter, or more frequently if the Clinical Supervisor has concerns about my standard of practice, commenting on the matters listed in (7)(c)(iv)7, and:
(i) support for my transition to independent practice in family medicine.
(v) Low Level Supervision will remain in place until the College determines, in its sole discretion, that it is no longer necessary.
(d) I, Dr. Kehoe, acknowledge that I have reviewed the Clinical Supervisor’s undertaking attached hereto as Appendix “A”, and understand what is required of the Clinical Supervisor. In addition to what is set out above, the Clinical Supervisor will, at a minimum:
(i) Facilitate the education program set out in the IEP, attached hereto as Appendix “B”;
(ii) Review the materials provided by the College and have an orientation session with me, including to discuss the objectives for the Clinical Supervision and practice improvement recommendations;
(iii) Remain free of any conflict of interest with me.
(e) I, Dr. Kehoe, acknowledge that the charts reviewed shall be selected by the Clinical Supervisor based on the educational needs identified in the IEP, attached hereto as Appendix “B”, and concerns that may arise during the period of Clinical Supervision.
(f) I, Dr. Kehoe, undertake to cooperate fully with the Clinical Supervision of my practice, conducted under the terms of this Undertaking and Appendix “A” to this Undertaking, and to abide by the recommendations of my Clinical Supervisor, including but not limited to, any recommended practice improvements and ongoing professional development.
(g) I, Dr. Kehoe, undertake to ensure that Appendix “A” to this Undertaking is signed and delivered to the College prior to commencing practice in family medicine.
(h) I, Dr. Kehoe, undertake that if a person who has given an undertaking in Appendix “A” to this Undertaking is unable or unwilling to continue to fulfill its provisions, I shall cease practising medicine until such time as I have obtained an executed undertaking in the same form from a similarly qualified person who is acceptable to the College.
(i) I, Dr. Kehoe, acknowledge that if I am required to cease practise as a result of section (7)(h) above this will constitute a term, condition or limitation on my certificate of registration and that term, condition or limitation will be included on the public register.
(j) I, Dr. Kehoe, undertake that if I am required to cease practise as a result of section (7)(h) above, I shall immediately forward a request to the General Manager of OHIP that my billing number be deactivated for services rendered after the date I cease to practise. Once I have obtained a Clinical Supervisor acceptable to the College, I may request that the General Manager of OHIP reactivate my billing number.
(8) Professional Education
(a) I, Dr. Kehoe, undertake to participate in and successfully complete all aspects of the detailed IEP, attached hereto as Appendix “B”, including all of the following professional education (the “Professional Education”):
(i) Review, reflection, and discussion with my Clinical Supervisor of the common primary guidelines, including but not limited to:
1. Diabetes Canada Guidelines;
2. Osteoporosis Canada Guidelines;
3. Hypertension Canada Guidelines;
4. Canadian Cardiovascular Society Guidelines;
5. Canadian Thoracic Society Guidelines (asthma and COPD);
6. Society of Obstetricians and Gynecologists Guidelines;
7. Canadian Pediatric Society Guidelines;
8. Ontario Immunization Schedule;
9. Cancer Care Ontario Screening Guidelines;
10. Canadian Task Force on Preventive Health Care;
11. Choosing Wisely Canada;
(ii) Review, reflection, and discussion with my Clinical Supervisor of common primary care problems, including:
1. management of common infections and antibiotic stewardship (ref: Public Health Ontario: Antimicrobial Stewardship in Primary Care and MUMS Anti-infective guidelines for Community Acquired Infections);
2. Infection Prevention and Control for Clinical Office Practice (Public Health Ontario and CPSO document);
(iii) Review, reflection, and discussion with my Clinical Supervisor of the following policies and other self-study:
1. Medical Records Documentation, College policy;
2. Good Practices – Physician-patient: Documentation and record keeping, CMPA;
3. CPSO Professionalism;
4. CMA Code of Ethics;
5. Good Practices – Professionalism and Ethics, CMPA;
6. The Time Management Guide, Royal College;
(iv) Review of the following policies and other self-study:
1. Canadian Medical Association’s Code of Ethics;
2. CPSO Practice Guide;
3. CPSO policies;
4. General Preamble of the Ontario Schedule of Benefits;
(v) fulfill, and review with my Clinical Supervisor, the CFPC’s requirements for CPD cycles;
(vi) any additional professional education recommended by my Clinical Supervisor.
(b) I, Dr. Kehoe, undertake to provide proof to the College of my successful completion of the Professional Education, including proof of registration and attendance and participant assessment reports, within one (1) month of completing it. I acknowledge that the College will determine, in its sole discretion, whether I have successfully completed the Professional Education.
(c) I, Dr. Kehoe, undertake to complete this requirement before the completion of Clinical Supervision, or, if no satisfactory program is available by that time, by the first possible opportunity thereafter.
(d) I, Dr. Kehoe, acknowledge that a report or reports may be provided to the College regarding my progress and compliance with the Professional Education.
(e) I, Dr. Kehoe, acknowledge that if any of the programs and/or self-study resources listed above become unavailable, substitution requests will be reviewed by the College and the College will determine in its sole discretion whether substitution is appropriate.
(9) Assessment of Practice
(a) I, Dr. Kehoe, undertake that, following completion of the Clinical Supervision set out in section (7) above and Appendix “A” to this Undertaking, and the completion of the Professional Education set out in section (8) above, I will submit to an assessment of my practice (“the Assessment”) by an assessor or assessors selected by the College (the “Assessor” or “Assessors”). I acknowledge that the Assessment will include a chart review of a minimum of twenty-five (25) charts, and may include direct observation of my care, interviews with me, colleagues and co-workers, feedback from patients, and any other tools deemed necessary by the College.
(b) I, Dr. Kehoe, undertake to co-operate fully with the Assessment conducted under the terms of this Undertaking.
(c) I, Dr. Kehoe, acknowledge that my Clinical Supervisor may receive and review the findings of the Assessor, and may discuss with the Assessor any issues or concerns arising from the Assessment.
(d) I, Dr. Kehoe, acknowledge that the results of the Assessment will be provided to me and reported to the College and the Assessment may form the basis of further action by the College.
(10) Monitoring
(a) I, Dr. Kehoe, undertake to inform the College of each and every one of my Practice Locations within five (5) days of executing this Undertaking. Going forward, I further undertake to inform the College of any and all new Practice Locations within five (5) days of commencing practice at that location.
(b) I, Dr. Kehoe, undertake that I will submit to, and not interfere with, unannounced inspections of my Practice Locations and patient records by a College representative for the purposes of monitoring my compliance with the provisions of this Undertaking.
(c) I, Dr. Kehoe, give my irrevocable consent to the College to make appropriate enquiries of OHIP and/or any person who or institution that may have relevant information, in order for the College to monitor my compliance with the provisions of this Undertaking.
(d) I, Dr. Kehoe, acknowledge that I have executed the OHIP consent form, attached hereto as Appendix “C”.
C. ACKNOWLEDGEMENT
(11) I, Dr. Kehoe, acknowledge that all appendices attached to or referred to in this Undertaking form part of this Undertaking.
(12) I, Dr. Kehoe, acknowledge and undertake that I shall be solely responsible for payment of all fees, costs, charges, expenses, etc. arising from the implementation of any of the provisions of this Undertaking.
(13) I, Dr. Kehoe, acknowledge that I have read and understand the provisions of this Undertaking and that I have obtained independent legal counsel in reviewing and executing this Undertaking, or have waived my right to do so.
(14) I, Dr. Kehoe, acknowledge that the College will provide this Undertaking to any Chief of Staff, or a colleague with similar responsibilities, at any Practice Location (“Chief of Staff” or “Chiefs of Staff”).
(15) I, Dr. Kehoe, acknowledge that a breach by me of any provision of this Undertaking may constitute an act of professional misconduct and/or incompetence, and may result in a referral of specified allegations to the Discipline Tribunal of the College.
(16) I, Dr. Kehoe, acknowledge that this Undertaking constitutes terms, conditions, and limitations on my certificate of registration for the purposes of section 23 of the Code.
(17) Public Register
(a) I, Dr. Kehoe, acknowledge that, during the time period that this Undertaking remains in effect, this Undertaking shall be posted on the Public Register.
(b) I, Dr. Kehoe, acknowledge that, in addition to this Undertaking being posted in accordance with section (17)(a) above, the following summary shall be posted on the Public Register during the time period that this Undertaking remains in effect:
Dr. Kehoe will practise under the guidance of a Clinical Supervisor acceptable to the College for a minimum of ten months.
Dr. Kehoe will engage in professional education, including in medical recordkeeping, common conditions managed in family medicine practice, effective communication with physicians and other members of the health care team, the Ontario health care system, appropriate professional behaviours and relationships, and ethical issues encountered in practice.
Dr. Kehoe’s practice will be assessed by an assessor selected by the College following the period of Clinical Supervision and the completion of the professional education.
(c) I, Dr. Kehoe, acknowledge that this Undertaking remains in effect until the College determines its terms are satisfied.
D. CONSENT
(18) I, Dr. Kehoe, give my irrevocable consent to the College to provide the following information to any person who requires this information for the purposes of facilitating my completion of the Professional Education and to all Clinical Supervisors, and/or Assessors:
(a) any information the College has that led to the circumstances of my entering into this Undertaking;
(b) any information arising from any investigation into, or assessment of, my practice; and
(c) any information arising from the monitoring of my compliance with this Undertaking.
(19) I, Dr. Kehoe, give my irrevocable consent to the College to provide all Chiefs of Staff with any information the College has that led to the circumstances of my entering into this Undertaking and/or any information arising from the monitoring of my compliance with this Undertaking.
(20) I, Dr. Kehoe, give my irrevocable consent to any persons who facilitate my completion of the Professional Education, and to all Clinical Supervisors, Chiefs of Staff and Assessors, to disclose to the College, and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant to the provisions of the Clinical Supervisor’s undertaking set out at Appendix “A” to this Undertaking;
(c) any information relevant to the Assessment;
(d) any information relevant for the purposes of monitoring my compliance with this Undertaking; and/or
(e) any information which comes to their attention in the course of providing the Professional Education and which they reasonably believe indicates a potential risk of harm to my patients.
Terms and conditions imposed on certificate by: Member