Introduction

Under Ontario law, certain acts, referred to as “controlled acts,” may only be performed by authorized regulated health professionals. Of the 14 controlled acts, physicians are authorized to perform 13 of them and under appropriate circumstances, physicians may delegate these acts to others.¹ While the term “delegation” can have multiple meanings, for the purposes of the policy, “delegation” is defined as a mechanism that allows a regulated health professional (e.g., a physician) who is authorized to perform a controlled act to temporarily grant that authori­ty to another person (whether regulated or unregulated) who is not legally authorized to perform the act independently. Delegating con­trolled acts in appropriate circumstances can result in more timely delivery of health care, promote optimal use of health­care resources and personnel, and increase access to care where there is a need.

The Delegation of Controlled Acts policy sets expectations for physicians about when and how they may delegate controlled acts, through either direct orders or medical directives. This companion Advice document is intended to help physicians interpret their obligations as set out in the Delegation of Controlled Acts policy and provide guidance around how these expectations may be effectively discharged.

Delegation Fundamentals

What should I do if I’m not sure whether a procedure, treatment, or intervention requires the performance of a controlled act?

Controlled acts are defined in the Regulated Health Professions Act, 1991² (RHPA) and are set out in the appendix of the policy. Physicians with questions about whether a procedure, treatment or intervention involves the performance of a controlled act can obtain a legal opinion.

What are some examples of instances that would not require delegation? In what circumstances does the policy not apply?

"Delegation” occurs only when a physician directs an individual to perform a controlled act that the individual has no statutory authority to perform. However, the term “delegation” is often used liberally to refer to instances that would not require delegation as defined in the policy. For example, the following would not require delegation as defined in the policy:

1. Assigning tasks to staff or other health care professionals that do not involve the performance of controlled acts (e.g., history-taking, administering a test that does not involve a controlled act, taking vitals, or obtaining consent).
2. Performing a controlled act in one of the permissible circumstances listed under the RHPA³ (e.g., when providing first aid or temporary assistance in an emergency or when fulfilling the requirements to become a member of a health profession (e.g., medical students)).
3. Ordering the initiation of a controlled act that is within the scope of practice of another health professional (e.g., an order for a nurse to “administer a substance by injection” is not delegation as nurses are legally authorized to perform this act when ordered to do so by a physician).⁴

In what circumstances can the emergency exception under the RHPA be relied upon to perform controlled acts and when is delegation required?

The emergency exception under the RHPA allows individuals to perform controlled acts when providing first aid or temporary assistance in an emergency. The exception allows individuals who come across a scenario requiring immediate action and assistance to perform controlled acts where necessary. For example, a bystander who encounters someone experiencing anaphylaxis and requiring administration of an epinephrine auto injector (e.g., EpiPen^TM). The individual would be permitted under the exception to perform the controlled act of administering the injection, an act that would otherwise require legal authority to perform.

The exception does not enable individuals who are otherwise unauthorized to perform controlled acts, to do so in circumstances where there is an anticipated emergency. For example, circumstances requiring trained emergency or first aid personnel to be on site in the event of an injury. In scenarios where first responders, including lay person first responders (e.g., lifeguards, ski patrol, wilderness first responders, occupational first aid providers, etc.) are hired to provide emergency services that might require the performance of controlled acts, the policy expectations do apply.

Delegation is the authorizing mechanism enabling lay person first responders to perform controlled acts when providing first aid in an emergency. The policy permits these instances of delegation in the absence of a physician-patient relationship, however, it still requires the other expectations to be satisfied, including ensuring a delegate’s competence, and that appropriate supervision and supports are in place to ensure safe and effective delegation (e.g., oversight by a Medical Director). Appropriate documentation is also required while recognizing that the nature of the care provided in these instances would not result in a typical patient medical record.

Performing tasks such as history-taking can be as important to the care provided as the performance of controlled acts. Why does the policy not apply to assignments of tasks that are not controlled acts?

Delegation is an enabling mechanism for the performance of acts that are otherwise restricted and thus a framework for delegation is necessary to provide clarity about how this can be done appropriately. Despite the policy’s focus on the delegation of controlled acts, physicians remain responsible for all the care that is provided on their behalf, and for ensuring those providing care can safely, effectively and ethically deliver all assigned components of care. The general principles set out in the policy to ensure that delegation is done appropriately can similarly guide physician judgment when determining the appropriateness of assigning tasks to others. As with all decisions related to the provision of care, patient best interests can be used as the guiding principle.

Considering and Evaluating Delegates

The policy requires that physicians not delegate to a health professional whose certificate of registration is revoked or suspended at the time of the delegation. What actions do I need to take to ensure compliance with this expectation?

The actions that physicians need to take to ensure compliance with this expectation are case specific and are generally dependent on a physician’s practice setting and their role in hiring. For physicians practising in institutional settings such as hospitals, unless there are reasonable grounds to believe otherwise, it would generally be acceptable to assume that the hiring institution has done their due diligence in this regard. All other physicians can confirm the status of a delegate’s certificate of registration by checking the health profession regulator’s registry or contacting the regulator directly for confirmation of whether the delegate’s practice certificate is in good standing. If a physician were to learn that an individual to whom they had been delegating had become suspended or their certificate of registration was revoked they would be expected to cease delegating to that individual immediately.

Can I delegate to individuals who are not members of a regulated health profession?

Yes. The policy permits delegating to individuals who are not members of a regulated health profession, provided the policy requirements are met. For example, Physician Assistants and paramedics are skilled health care providers who regularly provide safe and effective care entirely through delegation.

Physicians are ultimately responsible for the acts they delegate and must be satisfied that the individual to whom they are delegating has the requisite knowledge, skill, and judgment to perform the act(s).

Where can I find information about delegating to Physician Assistants (PAs)?

The Canadian Medical Association and the Canadian Association of Physician Assistants have developed a Physician Assistant Toolkit for Canadian physicians looking to delegate to PAs. The CMPA’s article Working with physician assistants: Collaborating while managing risks also contains helpful information.

How do the policy expectations apply when delegating to International Medical Graduates (IMGs) who have credentials or licences obtained in other jurisdictions but who do not have certificates of registration in Ontario?

The same protocols that apply when delegating to any other individuals apply to IMGs. In particular, physicians cannot rely exclusively on credentials or licences obtained in other jurisdictions to ascertain whether an IMG has the requisite knowledge, skill, and judgment to safely perform a controlled act and must be equally diligent in evaluating and establishing the IMG’s competence to perform the controlled acts as they would for any other delegate.

What are my responsibilities for ensuring competence if I am not involved in the hiring of the individual to whom I will be delegating (e.g., in an institutional setting)?

As part of establishing and ensuring a delegate’s competence the policy requires physicians to review the delegate’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. It is reasonable to rely on the diligence of the institution’s process for hiring unless there are reasonable grounds to believe otherwise. If a physician becomes aware that an individual to whom they are delegating does not have the knowledge, skill, or judgment to perform the delegated acts competently and safely they need to take appropriate action to inform the person or authority to whom the delegate is accountable.⁵

Scope of Practice

What does it mean to only delegate acts which are in my scope of practice? If I have a practice restriction, am I permitted to delegate?

Physicians are required by the policy to only delegate acts that they are competent to perform personally (i.e., those within their scope of practice). This means that physicians must only delegate acts that are within the limits of their knowledge, skill and judgment and any terms, limits and conditions of their practice certificate. Physicians are not permitted to delegate acts that contravene their practice restrictions.

Delegating in the Context of a Physician-Patient Relationship

Is it appropriate to delegate a cosmetic procedure (e.g., botulinum toxin (Botox^TM) and fillers) without first establishing a physician-patient relationship?

Generally, no. As the policy states, delegation must occur within the context of a physician-patient relationship, unless a patient's best interest dictates otherwise. It is generally in a patient’s best interest for a physician to conduct a clinical assessment and gather the necessary clinical information prior to delegating, so they can determine whether delegation is appropriate, including in the context of cosmetic procedures. As in all instances of delegation, a physician would have to justify why delegating in the absence of a physician-patient relationship is in a patient’s best interest.

Assessment of Risk

What are the risks involved in delegating? How does risk factor into decisions related to delegation?

By law, controlled acts may only be performed by authorized regulated health professionals due to the potential harm that could result if performed by someone who does not have the knowledge, skill, and judgment to perform them. As such, the performance of any controlled act has been identified by the legislature as carrying some risk.

Risks vary depending on the specific acts being performed and the circumstances under which they are performed and thus must be considered prior to each instance of delegation and mitigated appropriately. Physicians must then only delegate if the patient’s health and/or safety will not be put at risk by the delegation. Physicians who require additional assistance determining the appropriateness of delegating in a specific circumstance can contact the CMPA or obtain independent legal advice.

Appropriate Supervision and Support

Delegation is intended to be a physician extender, not a physician replacement. What does this mean and how can I apply this principle when delegating?

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. It is meant to be a tool to extend physician services, where appropriate, as opposed to replacing the physician altogether. In accordance with the policy, this requires physicians to appropriately supervise and support delegates, and not allow a delegate to practise independently without any physician involvement or beyond the scope of their individual knowledge, skills, and judgement. Ensuring appropriate parameters are placed around what a delegate is permitted to do, that are based on the individual’s education, training and experience is vital for safe and effective delegation.

I am required to appropriately supervise individuals to whom I am delegating. Am I required to be onsite when supervising a delegate?

Generally speaking, by fulfilling the requirements in the policy physicians will often already be onsite to supervise delegates. For example, when establishing a physician-patient relationship, providing an appropriate clinical assessment, re-assessing a patient as a result of a change in clinical status or treatment options, or when a patient has requested to see the physician.

Notwithstanding the above, the requirement to be onsite is case specific and dependent on the circumstances of the delegation. Supervision must be proportionate to the risks associated with the delegation and physicians need to be available to provide whatever support is required by the delegate. In some instances this will require you to be onsite, or to be available to come onsite if necessary, and in other instances you can provide assistance remotely, provided the right supports are in place in the setting where the delegation is occurring. Physicians need to carefully consider whether it is safe and appropriate to delegate while offsite and only do so where robust protocols are in place to ensure patient safety.

It is not appropriate for physicians to leave a delegate to manage a practice or their patient population on their own. Onsite supervision will help ensure the policy expectations are met.

What are some examples of circumstances where it might be appropriate to be offsite when supervising a delegate?

It may be appropriate for physicians to supervise delegates while offsite where the risk of the delegation is low, and/or the circumstances make it impractical or impossible to be onsite. For example, where delegation is occurring for the purpose of facilitating access to care where there is a need, it may not be possible for supervising physicians to be physically present at the location in which a delegate is providing care. Additionally, paramedicine is structured in a way that permits Base Hospital physicians to provide remote assistance where necessary and does not require onsite supervision. Lastly, physicians delegating in the context of long-term care homes may not always be onsite.

Ultimately, whether it is appropriate to be offsite at any given moment is case specific and physicians must be available to provide assistance to delegates, when necessary.

Quality Assurance

What are some best practices for monitoring and evaluating the delegation process?

Tracking or monitoring when medical directives are being implemented inappropriately or are resulting in unantici­pated outcomes can help monitor the effectiveness of the delegation process.

Delegating Prescribing

Am I permitted to delegate the controlled act of prescribing?

Yes, where appropriate. As with the delegation of all controlled acts, physicians must consider whether it is in the patient’s best interest to delegate prescribing, in the circumstances. Factors for consideration include the risk profile of the drug, the patient’s specific condition, whether the drug has been previously prescribed (repeats or renewals), whether the prescription requires adjustment, etc.

Can medical directives be used to implement orders for prescriptions?

Yes. Medical directives can be used to implement orders for prescriptions. Any prescriptions completed pursuant to a medical directive need to specifically identify the medical directive (name and number), the individual responsible for implementing the directive (name and signature), and the name of the prescribing physician, along with contact information to clarify any questions. If a request is received, a copy of the medical directive can be forwarded to further demonstrate the integrity of the order.

Documentation

How do I ensure appropriate documentation of delegation?

Medical records can provide indication of whether delegation is being done appropriately and in accordance with the policy. Therefore, in keeping with the principles and expectation of the College’s Medical Records Documentation policy, it is important for the medical records of patients who received care through delegation to accurately and comprehensively reflect the care that was provided (e.g., evidence of an appropriate history-taking, any relevant assessments that were done, informed consent in accordance with the policy, etc.). Additionally, where medical directives are implemented, physicians may wish to capture the name and number of the directive in the medical record.

Liability and Billing

Are there liability issues that arise from delegation?

Physicians are accountable and responsible for the acts that they delegate. In particular, they are responsible for making the choice to delegate, and for ensuring that the delegation is taking place safely, effectively, and in accordance with the policy expectations.

Physicians with questions about liability or liability protection can consult the CMPA. 

If I am fulfilling the CPSO’s expectations with respect to the delegation of controlled acts does that mean I have fulfilled the Ontario Health Insurance Plan (OHIP) billing requirements for delegated services?

No. Fulfilling the College’s expectations with respect to the delegation of controlled acts does not entail that physicians have fulfilled Ontario Health Insurance Plan (OHIP) billing requirements for delegated services. Physicians who bill OHIP and who are considering delegating performance of controlled acts to others need to carefully review the provisions of the OHIP Schedule of Benefits. The Ontario Medical Association (OMA) and the Provider Services Branch at OHIP can answer questions and give advice about such matters and a joint bulletin developed by the Ministry of Health and the OMA provides additional information on Payment Requirements for Delegated Services.

Endnotes

^1. Physicians are not permitted to delegate the controlled act of psychotherapy.

^2. Controlled acts are defined under subsection 27 (2) of the Regulated Health Professions Act, 1991, S.O. 1991, c. 18 (RHPA).

^3. The RHPA sets out a number of exceptions that allow individuals who are not members of a regulated health profession to perform some controlled acts, in certain circumstances. A comprehensive list of the exceptions can be found under Section 29 (1) (2) of the RHPA.

^4. In order to determine whether an act requires delegation, physicians need to be aware of the scope of practice of the individual who will perform the act and whether it includes the controlled act in question. Regulated health professions have their own professional statutes (e.g., the Nursing Act, 1991), that define their scopes of practice and the controlled acts they are authorized to perform. Physicians with additional questions can consult the CMPA or obtain an independent legal opinion.

^5. For additional information see the College’s Mandatory and Permissive Reporting policy.