Delegation to Physician Assistants

What is delegation?

Delegation is a mechanism that allows a regulated health professional (e.g., a physician) who is authorized to perform a controlled act to grant that authority to another person (whether regulated or unregulated) who is not legally authorized to perform the act independently.

Delegation is not required for tasks that are not controlled acts (e.g. taking a patient’s history).

As set out in the Delegation of Controlled Acts policy, delegation occurs through the use of a:

• medical directive: written orders by a physician to another health care provider that pertain to any patient who meets the criteria set out in the medical directive, and/or
• direct order: written or verbal instructions from a physician to another health care provider to carry out a specific treatment, for a specific patient, at a specific time.

Further information about delegation and the use of medical directives can be found in the Delegation of Controlled Acts policy and companion Advice document.

What is sub-delegation and why is it prohibited?

Sub-delegation occurs when a person who accepts delegation further delegates the same act to another person. The Regulated Health Professions Act, 1991 (RHPA) prohibits the sub-delegation of controlled acts by stating that these acts can only be performed by individuals who are authorized by legislation to perform them or who have received delegation from someone who is authorized by legislation to perform them. In the interest of patient safety, sub-delegation is prohibited across health professions.

However, the RHPA sets out exceptions to this, enabling otherwise unauthorized individuals to perform controlled acts in the following scenarios:

• rendering first aid or temporary assistance in an emergency
• 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 done under the supervision or direction of a member of the profession
• treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment
• treating a member of the person’s household [for specific controlled acts, e.g. administering insulin by injection] and
• assisting a person with his or her routine activities of living [for specific controlled acts e.g. catheter care].

Does the prohibition on sub-delegation impact a PA’s ability to supervise or train PA students?

No. The Regulated Health Professions Act, 1991 allows students to perform controlled acts when “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 done under the supervision or direction of a member of the profession.”

This extends to PA students, which means that they can perform controlled acts under supervision when training to become a member of the profession, without the need for the acts to be delegated to them. For example, a PA may ask a PA student to perform joint reduction under the PA’s supervision. This does not amount to sub-delegation.

Can PAs sign orders written by PA students?

Yes. PAs can sign orders written by PA students, where they do so with reference to the relevant medical directive that grants them the authority to implement the order. In situations where medical directives are not established, the supervising physician would need to co-sign the order.

Can PAs participate in the training of medical students and residents?

Yes. There is nothing in the regulations preventing PAs from participating in the training of medical students and residents, where appropriate.

Can PAs communicate orders to other regulated health care professionals?

Yes. PAs and other regulated health care professionals work together to provide patient care, often through the use of medical directives. The medical directive is commonly used to authorize/enable PAs and other health care professionals to implement the orders of physicians. When practising under a medical directive, PAs are not ordering independently, they are implementing a physician's order for a treatment plan.

Accordingly, when a health care professional accepts an order through a PA, they are not directly accepting the order from the PA but are carrying out the physician’s order under the medical directive, based on their own assessment of its appropriateness and whether it is within their scope of practice. For example, under a medical directive, a PA can communicate an order to a nurse to provide a patient with an antibiotic.

Is the physician required to be onsite when supervising a PA?

Not in all instances. CPSO’s Delegation of Controlled Acts policy sets out the expectations of physicians who delegate a controlled act to another individual, including a PA. It requires that physicians provide a level of supervision and support that is proportionate to the risk associated with the delegation, among other factors. If the physician feels that onsite supervision is not necessary based on the risk assessment, the policy requires that physicians be available to provide appropriate consultation and assistance.

Can a PA have more than one physician supervisor?

There is nothing in the regulations preventing a PA from accepting delegation from more than one physician. However, it is best practice to ensure that there is an identified lead physician supervisor, commonly the most responsible physician (MRP) where applicable, to ensure that the chain of accountability and communication is clear.

What is meant by “psychotherapy”? Why can’t PAs be delegated the act of psychotherapy?

The controlled act of psychotherapy is defined in the Regulated Health Professions Act, 1991 and is comprised of the following five elements being performed together:

1. treating
2. by means of psychotherapy technique
3. delivered through a therapeutic relationship
4. an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that
5. may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning

CPSO’s Delegation of Controlled Acts policy prohibits the delegation of the controlled act of psychotherapy because of the unique, sensitive nature of the psychotherapeutic relationship between a health care provider and a patient. This prohibition is consistent with the rules of other regulated health care professionals.

However, PAs are not prevented from practising in mental health facilities or providing information, support, or counselling to patients requiring mental health care. This does not constitute the controlled act of psychotherapy, which involves performing all five elements together.

PAs who would like to provide psychotherapy are not prevented from becoming a member of a regulated profession that is independently authorized to perform psychotherapy (e.g., nurse, occupational therapist, physician, psychologist and/or psychological associate, and social worker and/or social service worker). In this case, PAs will be required to meet the standards of the profession set out by the specific regulatory body and ensure that the patient is aware that they are providing psychotherapy as a licensed member of the authorized profession, and not as a PA.

For more information on the controlled act of psychotherapy, please refer to the What is Psychotherapy? page on the College of Registered Psychotherapists of Ontario’s website.

Can PAs prescribe medication independently?

No. PAs may only prescribe medication through delegation and where a medical directive is in place, or a direct order has been provided by the physician. A prescription written by a PA through delegation should include:

• that the prescription was generated via delegated authority (e.g., direct order or medical directive number)
• the authorizing physician’s name and contact information and
• the prescribing PA’s designation, name, contact information and signature.

More Information

If you have additional questions, please contact [email protected].