Delegation of Controlled Acts

Approved policy has clear focus on right-touch regulation

CPSO’s recently updated Delegation of Controlled Acts policy is an example of how the College continues to develop policy within a risk-based framework and with a clear focus on right-touch regulation.

The policy, which was approved at the March 2021 Council meeting, recognizes that delegation occurs in a variety of contexts, and a one-size-fits-all approach can’t be prescribed for every instance. Instead, the policy contains foundational principles for delegation that can be applied to a variety of scenarios.

Dr. Sarah Reid, a policy working group member and Ottawa pediatric emergency medicine physician, explains that a principled approach to the policy enables flexibility in practice depending on a variety of considerations, and recognizes that the risk profile of the delegation is going to drive many of the decisions around what is appropriate. Such considerations include whether it is appropriate to delegate at all, what appropriate supervision looks like, whether the physician needs to be onsite when supervising, the steps required to determine a delegate’s competence, and the nature of the quality assurance/ongoing monitoring and evaluation process to ensure delegation is occurring appropriately.

“Delegation should only occur where risks can be mitigated appropriately,” said Dr. Reid. “The settings where the delegation is occurring, the acts being delegated, and the education, training and experience of the delegate are all factors that matter, and change the risk profile of the 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 as carrying some risk.

The policy makes clear that 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.

“A risk-based approach allows physicians to use their professionalism and professional judgment, while providing parameters that protect patient safety,” said Dr. Reid.

Key aspects of the revised policy

Clarifying the difference between “delegation” and assignments of tasks that do not involve the performance of controlled acts. While the policy focuses on delegation exclusively, new content in the Advice document addresses the importance of both in the delivery of care and that physicians are responsible for all the care that is provided on their behalf.

Clarifying what it means to delegate in the patient’s best interest (i.e., only delegating where the patient’s health and safety won’t be put at risk, quality of care won’t be compromised and the delegating serves at least one of the following purposes: promotes patient safety, facilitates access to care where there is a need, results in more timely or efficient delivery of health care, and/or contributes to optimal use of health-care resources).

Setting an expectation that where the risk profile allows for physicians to be offsite, they must continue to be available to provide appropriate consultation and assistance (e.g., in person, if necessary, or by telephone).

Retaining delegation in the context of a physician-patient relationship as the standard, while clarifying the exceptions to that requirement, including permitting community paramedicine programs, all public health programs, and lay-person first responders to operate in the absence of a traditional physician-patient relationship.

Being clear that it would be inappropriate to delegate to individuals who have been identified by the College as individuals who have inappropriately claimed to be or posed as a physician (described as “Unregistered Practitioners”). Direction is also included on where information about unregistered practitioners is posted on our website.

Clarifying that lay person first responders (e.g., lifeguards, ski patrol, wilderness first responders, occupational first aid providers, etc.) require delegation in order for them to provide care, and outlining how the policy applies in these scenarios.