Delegation of Controlled Acts

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Physicians need to be available to provide whatever support is required

The College often receives inquiries from both doctors and patients about what appropriate supervision entails in the context of the delegation of controlled acts. A proposed policy makes it clear that delegation is intended to be a physician extender, not a physician replacement, with physicians remaining accountable and responsible for the patient care provided through delegation.             

The requirement to be onsite is case specific and dependent on the circumstances of the delegation, said Dr. Keith Hay, a CPSO medical advisor and member of the policy working group. “Supervision must be proportionate to the risks associated with delegation and physicians need to be available to provide whatever support is required by their delegate,” he said.

In many instances, this will require physicians to be onsite, or to be available to come onsite. Remote supervision, however, can be appropriate if the right supports are in place for delegation, he said.

“It is not appropriate for physicians to leave a delegate to manage a practice or their patient population on their own,” he said, noting that there have been cases seen at the College’s Inquiries, Complaints and Reports Committee where physicians have gone on vacation or even left the country for extended periods of time while leaving a delegate in charge of the practice, with no other supports in place.

In an attempt to pre-empt such situations, the draft policy contains new expectations that effectively prohibit physicians from leaving delegates unsupervised:

  • A requirement that physicians re-assess patients when their treatment options have changed or upon patient request.
  • A requirement that physicians periodically review patient medical records to ensure appropriate care is being provided through delegation.
  • A statement reminding physicians that a delegate is a physician extender not a physician replacement.

The proposed policy states that if, on the basis of a risk assessment, the physician believes that onsite supervision is not necessary, they must be available to provide appropriate consultation and assistance (e.g., in person, if necessary or by telephone).

Types of Concerns seen by the College

Complaints and concerns about delegation continue to be an issue seen by the College. The following are some examples of the types of cases ICRC sees frequently:

  1. Delegating in the absence of a physician-patient relationship. We receive frequent complaints regarding delegating with no initial physician assessment or physician-patient relationship. The draft policy clarifies the limited circumstances in which it would be appropriate to delegate in the complete absence of a physician-patient relationship. The Advice reinforces that delegating absent a physician-patient relationship is the exception not the rule.
  2. Ongoing treatment by delegates with little or no physician involvement. These instances see delegates treating patients regardless of the clinical issue, with the patient never seeing their physician. The draft policy contains new provisions to address ongoing delegation.
  3. No authorization mechanism or insufficient detail in medical directives. In some cases, delegation has been authorized absent a medical directive or direct order, or via an inappropriate medical directive, such as a medical directive that is too broad (i.e., not specifying the conditions or circumstances that must exist prior to a treatment or procedure being carried out). The draft policy clarifies that 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.
  4. Delegation that is not in the patient’s best interest but is driven by monetary gain or physician convenience. The draft policy clarifies that delegation must always be in the patient’s best interest and highlights appropriate and inappropriate reasons for delegating.