Professional Obligations: Delegation of Controlled Acts

Professional Obligations

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

1. Physicians must only delegate a controlled act when doing so does not compromise the patient’s health, safety and quality of care.

When Not to Delegate

2. Physicians must not delegate when the primary reasons for delegating are for monetary gain and/or physician convenience.
3. Physicians must not delegate the controlled act of psychotherapy.

How to Delegate

4. Physicians must delegate either through the use of a direct order or a medical directive that is clear and includes sufficient detail to facilitate safe and appropriate implementation (see the Medical Directives section below for more information).
5. Physicians must only delegate in the context of an existing or anticipated physician-patient relationship.
6. Physicians must clinically assess all new patients¹ prior to delegating or, where this is not possible, within two business days of the delegate’s first encounter with the patient, except in the following circumstances:
   1. Care provided by paramedics, community paramedics, or hospital transport teams;
   2. Care provided in remote and isolated regions of the province by registered nurses, registered practical nurses, or physician assistants;
   3. Care provided as part of public health initiatives, such as immunizations;
   4. Urgent care provided during a public health emergency declared by a public health authority;
   5. Postexposure prophylaxis or vaccination administered following potential exposure to a blood borne pathogen; and
   6. Care provided in hospital emergency departments.

7. Where 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 communicate directly with the physician if they wish to; and
   2. Periodically re-assess the patient (e.g., when there is a change in the patient’s clinical status or treatment options) to ensure that delegation continues to be in the patient’s best interest.

Supervising and Supporting Delegates

8. Physicians must not leave a delegate to manage a practice or their patient population on their own.
9. Physicians must be physically onsite to supervise and support delegates, unless:
   1. The delegation is occurring in the absence of a physician-patient relationship (as set out in provisions 6 (a) to (f)),
   2. Another physician who is able to support the delegate as necessary is physically onsite², or
   3. The risk associated with the delegation is low.³ 

10. Where the delegating physician is not onsite, they must be available to provide appropriate consultation and assistance within short notice (e.g., in person, if necessary).

What to Delegate

11. Physicians must only delegate controlled acts that they can perform competently (i.e., acts within their scope of practice).

Who to Delegate to

12. Physicians must take reasonable steps to ensure that delegates have the knowledge, skill, and judgment to perform the delegated acts competently and safely.

13. Physicians must not delegate a controlled act to:
    1. Health professionals whose certificate of registration is revoked or suspended; or
    2. Individuals who have falsely claimed to be or have posed as a physician.⁴

Identification of Roles

14. Physicians must ensure that delegates accurately identify themselves and their role in providing care to patients.

Consent to Treatment

15. Physicians must ensure consent discussions include informing the patient that a delegate will be involved in their care.

Managing Adverse Events

16. Physicians must have protocols in place to ensure adverse events are appropriately managed, including ensuring they are informed of any adverse events that take place and are available to help manage adverse events, if necessary.

Ongoing Monitoring and Evaluation

17. Physicians must have a reliable and ongoing monitoring and evaluation system for both the delegate(s) and the delegation process itself. At minimum, physicians must review patient medical records to ensure the care provided through delegation is appropriate and meets the standard of care.

Medical Directives

18. Physicians must ensure medical directives include:
    1. The name and description of the procedure, treatment, or intervention being ordered, with sufficient detail to support safe implementation;
    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;
    6. The name and signature of the physician(s) authorizing and responsible for the directive and the date it becomes effective; and
    7. A list of the administrative approvals that were provided to the directive, including the dates and each committee (if any).
19. Each physician responsible for the care of a patient who may receive the proposed treatment, procedure, or intervention must review and sign the medical directive each time it is updated.⁵

Medical Records

20. Physicians must ensure that:
    1. The care provided through delegation is documented in accordance with CPSO’s Professional Obligations: Medical Records Documentation, including that each entry in the medical record clearly conveys who made the entry and performed the act⁶;
    2. It is clear who the authorizing physician(s) are; 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.

Glossary

Controlled Acts: Controlled acts are specified in section 27 (2) of the Regulated Health Professions Act, 1991. These acts may only be performed by authorized regulated health professionals or through delegation under appropriate circumstances.

Delegation: Delegation allows a regulated health professional (e.g., a physician) who is authorized to perform a controlled act to temporarily grant that authority to another individual(s) (whether regulated or unregulated) who is not legally authorized to perform the act independently. Delegation does not include:

• Assignments of tasks that do not involve controlled acts (e.g., taking a patient’s history, obtaining informed consent to treatment, taking vitals, etc.).
• Controlled acts that other regulated health care professionals are authorized to perform.
• Controlled acts performed by “residents” or “fellows”.
• Controlled acts performed under one of the exceptional circumstances listed under section 29(1) of the Regulated Health Professions Act, 1991. For example:
  • When providing first aid or temporary assistance in an emergency; or
  • When training to become a member of a health profession and the act is within the scope of practice of that profession and is done under the supervision or direction of a member of the profession (e.g., medical students).

Direct Order: Direct orders are written or verbal instructions from a physician to another individual or group of individuals (regulated or unregulated) authorizing them to carry out a specific treatment, procedure, or intervention for a specific patient, at a specific time.

Medical Directive: Medical directives are written orders by physician(s) to another individual or group of individuals (regulated or unregulated) that pertain to any patient who meets the criteria set out in the medical directive. Medical directives provide the authority to carry out the treatments, procedures, or other interventions that are specified in the directive, provided that certain conditions and circumstances exist.