Delegation of Controlled Acts

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct. Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice. Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.

Definitions

Direct Order: Direct orders are written or verbal instructions from a physician to another health care provider or a group of health care providers to carry out a specific treatment, procedure, or intervention for a specific patient, at a specific time. Direct orders provide the authority to carry out the treatments, procedures, or other interventions that have been directed by the physician and generally take place after a physician-patient relationship has been established.

Medical Directive 4 : Medical directives are written orders by physician(s) to other health care provider(s) that pertain to any patient who meets the criteria set out in the medical directive. When a medical directive calls for acts that need to be delegated, it provides the authority to carry out the treatments, procedures, or other interventions that are specified in the directive, provided that certain conditions and circumstances exist.

Policy

Delegation is intended to provide physicians with the ability to extend their capacity to serve patients by temporarily authorizing an individual to act on their behalf. Delegation is intended to be a physician extender, not a physician replacement. Physicians remain accountable and responsible for the patient care provided through delegation.

When to Delegate

In the patient’s best interest

  1. Physicians must only delegate controlled acts when doing so is in the best interest of the patient. This includes only delegating when the act can be performed safely, effectively, and ethically. Therefore, physicians must only delegate when:
    1. the patient’s health and/or safety will not be put at risk;
    2. the patient’s quality of care will not be compromised by the delegation; and
    3. delegating serves at least one of the following purposes:
      1. promotes patient safety,
      2. facilitates access to care where there is a need,
      3. results in more timely or efficient delivery of health care, or
      4. contributes to optimal use of health­care resources.

      When not to delegate

      1. Physicians must not delegate where the primary reasons for delegating are monetary or physician convenience.
      2. Physicians must not delegate the performance of a controlled act to:
        1. a health professional whose certificate of registration is revoked or suspended at the time of the delegation 5 ; or
        2. unregistered practitioners 6 (i.e., individuals who have claimed to be or have posed as a physician).

        What to Delegate

        1. Physicians must only delegate the performance of controlled acts that they can personally perform competently (i.e., acts within their scope of practice). 8

        How to Delegate

        Use of direct orders and medical directives

        1. Physicians must delegate either through the use of a direct order or a medical directive that is clear, complete, appropriate, and includes sufficient detail to facilitate safe and appropriate implementation (see the Documentation section of this policy for more information).

        In the context of a physician­−patient relationship

        1. Physicians must only delegate in the context of an existing or anticipated physician-patient relationship, unless a patient’s best interest dictates otherwise (e.g., public health or public safety measures). 9
        2. Physicians must perform a clinical assessment prior to delegating or as soon as possible afterward, unless a patient’s best interest dictates otherwise.
        3. Where, in the context of a physician-patient relationship, delegation is occurring on an ongoing basis, physicians must:
          1. ensure that patients are informed of who the delegating physician is and that they can make a request to see the physician if they wish to; and
          2. periodically re-assess 10 the patient to ensure that delegation continues to be in the patient’s best interest (e.g., when there is a change in the patient’s clinical status or treatment options).

          Ensure consent to treatment is obtained

          1. Physicians must ensure informed consent is obtained and documented, in accordance with the Health Care Consent Act, 1996 and the College’s Consent to Treatment policy, for any treatments that are delegated. 11
            1. In circumstances where the delegation takes place pursuant to a medical directive, physicians must ensure the medical direc­tive includes obtaining the appropriate patient consent. 12

            Quality Assurance

            Identifying and mitigating risks

            1. Prior to delegating, physicians must identify significant or common risks associated with the delegation and mitigate them such that patient safety is at no greater risk than had the act not been delegated.
              1. Physicians must only delegate controlled acts if the necessary resources and environmental supports are in place to ensure safe and effective delegation.

              Evaluating delegates and establishing competence

              1. Physicians must be satisfied that individuals to whom they delegate have the knowledge, skill, and judgment to perform the delegated acts competently and safely. Prior to delegating physicians must:
                1. review the individual’s training and credentials, unless the physician is not involved in the hiring process and it is reasonable to assume that the hiring institution has ensured that its employees have the requisite knowledge, skill, and judgment 13 ; and
                2. observe the individual performing the act, where necessary (e.g., where the risk is such that observation is necessary to ensure patient safety).

                Ensuring delegates can accept the delegation

                1. Physicians must only delegate to individuals who are able to accept the delegation. 14 In particular, physicians must not:
                  1. delegate to an individual if they become aware the individual is not permitted to accept the delegation; or
                  2. com­pel an individual to perform a controlled act they have declined to perform.

                  Supervision and support of delegates

                  1. Physicians must provide a level of supervision and support that is proportionate to the risk associated with the delegation and that is reflective of the following factors:
                    1. the specific act being delegated;
                    2. the patient’s specific circumstances (e.g., health status, specific health-care needs);
                    3. the setting where the act will be performed and the available resources and environmental supports in place; and
                    4. the education, training and experience of the delegate.
                    1. understand the extent of their responsibilities; and
                    2. know when and who to ask for assistance, if necessary.

                    Managing adverse events

                    1. Physicians must:
                      1. have protocols in place to appropriately manage any adverse events that occur;
                      2. be available to provide assistance in managing any adverse events, if necessary;
                      3. be satisfied that the delegate is capable of managing any adverse events themselves, if necessary; and
                      4. have a communication plan in place to keep informed of any adverse events that take place and any actions taken by the delegate to manage them.

                      Ongoing monitoring and evaluation

                      1. Where acts are routinely delegated, physicians must have a reliable and ongoing monitoring and evaluation system for both the delegate(s) and the delegation process itself.
                      2. As part of this system, physicians must:
                        1. confirm currency of the delegate’s knowledge and skills; and
                        2. evaluate the delegation process to ensure it is safe and effective; and
                        3. review patient medical records to ensure the care provided through delegation is appropriate and meets the standard of practice.
                          1. What is necessary will depend on the specific acts being delegated and the other quality assurance processes in place to ensure safe and effective delegation.

                          Documentation

                          Medical Directives

                          1. Physicians must ensure the following information is included in the medical directive 15 :
                            1. The name and a description of the procedure, treat­ment, or intervention being ordered;
                            2. An itemized and detailed list of the specific clinical conditions that the patient must meet before the directive can be implemented;
                            3. An itemized and detailed list of any situational circum­stances that must exist before the directive can be implemented;
                            4. A comprehensive list of contraindications to implemen­tation of the directive;
                            5. Identification of the individuals authorized to imple­ment the directive; 16 >
                            6. A description of the procedure, treat­ment, or intervention itself that provides sufficient detail to ensure that the individual implementing the directive can do so safely and appropriately; 17
                            7. The name and signature of the physician(s) authorizing and responsible for the directive and the date it becomes effective; and
                            8. A list of the administrative approvals that were provided to the directive, including the dates and each committee (if any).

                            Medical Records

                            1. Physicians must ensure that:
                              1. the care provided through delegation is documented in accordance with the College’s Medical Records Documentation policy, including that each entry in the medical record is identifiable and clearly conveys who made the entry and performed the act;
                              2. it is clear who the authorizing physician(s) are (e.g., the name(s) of the authorizing physician(s) are captured in the medical record); and
                              3. verbal direct orders are documented in the patient’s medical record by the recipient of the direct order and are reviewed or confirmed at the earliest opportunity by the delegating physician. 19

                              Appendix A

                              Controlled Acts under the RHPA

                              1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disor­der as the cause of symptoms of the individual in cir­cumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
                              2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
                              3. Setting or casting a fracture of a bone or a dislocation of a joint.
                              4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
                              5. Administering a substance by injection or inhalation.
                              6. Putting an instrument, hand or finger,
                                1. beyond the external ear canal,
                                2. beyond the point in the nasal passages where they normally narrow,
                                3. beyond the larynx,
                                4. beyond the opening of the urethra,
                                5. beyond the labia majora,
                                6. beyond the anal verge, or
                                7. into an artificial opening in the body.

                                Endnotes

                                1. See Appendix A for a list of controlled acts defined under subsection 27 (2) of the Regulated Health Professions Act, 1991, S.O. 1991, c. 18 (RHPA).

                                2. Although the RHPA prohibits performance of controlled acts by those not specifically authorized to perform them, it permits performing controlled acts if the person performing the act is doing so to render first aid or temporary assistance in an emergency, or if they are fulfilling the requirements to become a member of a health profession and the act is within the scope of practice of the profession and is performed under the supervision or direction of a member of the profession (RHPA, s. 29(1)(a,b)).

                                3. For additional information about what is not considered “delegation” as defined in the policy, see the Advice to the Profession: Delegation of Controlled Acts document.

                                4. For examples of prototype medical directives, please consult the Emergency Department Medical Directives Implementation Kit which has been developed jointly by the Ontario Hospital Association (OHA), the Ontario Medical Association, and the Ministry of Health and is available on the OHA website.

                                5. For additional information about determining the status of a health professional’s certificate of registration, see the Advice to the Profession: Delegation of Controlled Acts document.

                                6. For a list of individuals identified by the CPSO see the CPSO’s website.

                                7. This does not prohibit health care professionals who are authorized to perform the controlled act of psychotherapy from doing so, including nurses of all classes, psychologists, occupational therapists, social workers, and registered psychotherapists.

                                8. O. Reg. 865/93, Registration, enacted under the Medicine Act, 1991, S.O. 1991, c.30, s. 2(5) requires physicians to only practise in the areas of medicine in which they are trained and experienced. For more information see the College’s Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy and the Delegation of Controlled Acts: Advice to the Profession document.

                                9. Generally, a patient’s best interests will be served by delegation that occurs in the context of an existing or anticipated physician-patient relationship. However, in some instances a patient’s best interests might be served by receiving care in the absence of a traditional physician-patient relationship. For example, in instances where access would otherwise be compromised to the point of risking patient safety, or where patient or public safety might be otherwise compromised. Examples of appropriate circumstances in which delegation may occur in the absence of a traditional physician-patient relationship include, but are not limited to:

                                • the provision of care by paramedics under the direct control of base hospital physicians or within community paramedicine programs;
                                • the provision of primary care in remote and isolated regions of the province by registered nurses acting in expanded roles;
                                • the provision of public health programs, such as vaccinations;
                                • post­exposure prophylaxis following potential exposure to a blood borne pathogen or the provision of the hepatitis B vaccine in the context of occupational health medicine;
                                • hospital emergency departments for routine protocols; and
                                • lay person first responders performing controlled acts for the purposes of first aid in an emergency.

                                10. In some circumstances, an assessment might take the form of a chart review or consultation with the delegate rather than an in-person assessment.

                                11. Please see the Health Care Consent Act, 1996 and the College’s Consent to Treatment policy for more information.

                                12. Obtaining informed consent includes providing the patient with information about the individual who will be providing the treatment and their role and/or credentials. Obtaining informed consent also includes the provision of information and the ability to answer questions about the material risks and benefits of the procedure, treatment or intervention proposed. If the individual who will be enacting the medical directive is unable to provide the information that a reasonable person would want to know in the circumstances, the implementation of the medical directive is inappropriate.

                                13. In some cases, the physician may not personally know the individual to whom they are delegating. For example, medical directors at base hospitals delegating to paramedics or in hospital settings, where the hospital employs the delegates (nurses, respiratory therapists, etc.) and the medical staff is not involved in the hiring process. For additional guidance about ensuring competence when a physician has not personally employed a delegate, see the Advice to the Profession: Delegation of Controlled Acts document.

                                14. In addition to the limitations set out in the RHPA, some regulatory colleges in Ontario place limits on the types of acts that their members may be authorized to carry out through delegation. The delegate is responsible for informing the delegating physician of any regulations, policies, and/or guidelines of their regulatory body that would prevent them from accepting the delegation.

                                15. A comprehensive guide and toolkit was developed by a working group of the Health Profession Regulators of Ontario (HPRO) in 2006 and is posted on their website.

                                16. The individuals need not be named but may be described by qualification or position in the workplace.

                                17. The directive may call for the delegate to follow a protocol that describes the steps to be taken in delivering treatment if one has been developed by the physician or the institution.

                                18. It is acceptable for physicians working at institutions with multiple directives to receive copies of each directive and sign one statement indicating that they have read and agreed with all the medical directives referred to therein. This can be done as part of the annual physician reappointment process.

                                19. Physicians practising in hospitals may be subject to additional requirements under the Public Hospitals Act, 1990.

                                20. This is the only controlled act that physicians are not authorized to perform.