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FREQUENTLY ASKED QUESTIONS

The questions, responses and principals illustrated in the profession-specific examples used in this section may be applied to any profession. For questions regarding profession-specific matters, contact the relevant College.

 

 

 

 

Understanding directives and delegation looks rather complicated. There seems to be a lot of information. Can I simply use the templates?

Understanding directives and delegation can appear rather complicated because of the different points of view that exist depending on the profession, setting and applicable health legislation. Reconciling the apparent contradictions and reaching consensus across all points of view is essential to enabling multi-professional care in any setting, and the information required to achieve this can seem rather extensive.

 

The templates are tools for establishing both directives and delegation. They incorporate the information identified in the guidelines and apply to all settings and professions, so you may use them on their own if you wish, referring to the guidelines for backup if necessary. In addition to being used for directives and delegation, the templates may also be used to assist with making decisions regarding performing procedures that may not require a directive or delegation, but are beyond principal expectations of practice for proposed implementers. The templates may be used as documents themselves, or they may serve as a guide to assist with decision-making or for developing setting specific documents.

 

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I see there are two templates for delegation - the Medical Directive and/or Delegation Template and the Delegation Template. Why? How do I know which one to use?

There are two templates for delegation because there are two types of authorizers who have different types of authority when it comes to ordering and delegating controlled acts under the Regulated Health Professions Act. The templates readily identify the differences and thus eliminate any margins for error that may result.

  • The Medical Directive and/or Delegation Template is used to designate an order (directive) that includes a delegation where necessary. Authorizers who have legislative authority to order procedures as well as to delegate their authorized acts under the RHPA may use it, including audiologists, chiropodists, podiatrists, dentists, midwives, optometrists, physicians, and registered nurses in the extended class. For example, physicians may use the Medical Directive and/or Delegation Template as an order to permit nurses and medical radiation technologists to requisition and take extremity x-rays respectively, or to permit OTs to perform a delegated act of setting or casting fractures.
  • The Delegation Template is used to designate a delegation by authorizers who have delegating authority under the RHPA, but who do not have legislative ordering authority. It would not be used to designate an order - the additional authority necessary to implement the procedure in a given situation. For example, respiratory therapists may use the Delegation Template to delegate oxygen administration to physiotherapists on condition of an order from a physician, in accordance with the requirements for orders identified in the Respiratory Therapy Act.

To decide which template to use, if you are, or are looking for authority from an authorizer with ordering and delegating authority, you would use the Medical Directive and/or Delegation Template. If you are, or are looking for authority from an authorizer with delegating but not ordering authority, you would use the Delegation Template.

 

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The process for developing a directive seems quite involved. Are there other less involved ways to authorize and implement best practices?

It is true that developing a directive can be involved but it is necessary to assure appropriate, coordinated care and patient safety, particularly in larger settings. There are other ways to authorize and implement best practices that are less involved because the decision to implement the order remains solely with a physician or appropriate authorizer and thus does not require the same degree of pre-planning to ensure coordination and appropriateness. Order sets, also known as pre-printed orders, may include treatments recommended by team members that physicians/authorizers may order when completing the order set. For example, recommended dietary supplements may be included in admission order sets used in a hospital setting. Care maps, protocols or procedures are other mechanisms that enable a physician or authorizer to order agreed upon directions contained in such mechanisms. For example, specific diagnostic tests and interventions may be identified in a care map and they may be implemented upon an order to activate the care map given by a physician or appropriate authorizer.

 

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How do I know if I am competent to perform a delegated procedure or any procedure that is beyond my principal expectations of practice? How does an authorizer know I'm competent?

You know you are competent when under the circumstances in the situation, you can reliably demonstrate the knowledge, skills and judgment necessary to perform and manage the outcomes of performing a procedure safely, effectively and ethically in accordance with current best practices and standards of practice for your profession. You may verify competence through consultation with the literature and experts, through successful completion of relevant courses and through supervised practice where a competent practitioner observes and gives feedback on your performance. In the event you are told you are competent, yet you do not believe you are, you would be expected to take the appropriate action to address patient best interests.

 

Prior to authorizing performance of a procedure, authorizers are responsible for taking reasonable measures to assure that implementers are competent to perform the procedure given the circumstances in the situation. If regulated implementers hold themselves out as competent, authorizers may rely upon this unless there is evidence to suggest an implementer is not competent. Other reasonable measures by which an authorizer may affirm your competence may include directly observing your practice, affirming completion of relevant courses that indicate achievement of competence or accepting an employer's appropriate assurances of your competence.

 

See How Does Accountability Work? for information on what accountabilities for competence are.

 

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Once I've been authorized to perform a delegated controlled act in one setting, can I perform it in another setting, or do I have to be authorized again?

If you change settings, you do not lose your competencies. However, you and the authorizers and manager responsible for care in another setting do need to be sure that performing the delegated act is appropriate given all the circumstances in the new situation, be it a new organization or a new team within the same organization. This includes assuring that the appropriate authority is in place, for example that the applicable authorizers have signed off on the practice prior to going ahead with performance.

 

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If I've been authorized to perform a procedure under a directive, can I assign aspects of performance to an assistant?

It depends. If the procedure is within your principal expectations of practice and authorized acts, if the assistant has the necessary competencies, if you can provide the appropriate level of supervision and if the authorizers and your employer where applicable agree with the practice, it may be appropriate. It would not be appropriate to assign the decision regarding when to perform the procedure made under the directive to an assistant. As well, if the procedure is a delegated act in the RHPA sense, it would not be appropriate to assign performance to the assistant because this would be a sub-delegation and in the interests of public protection, sub-delegation is not permitted. For example, a physiotherapist who has determined that mobilization is indicated in accordance with a post-op mobilization directive may assign an assistant to assist a patient with certain movements. However, the physiotherapist would not assign the assistant to decide when mobilization is indicated and would not include patients who require administration of oxygen (a delegated act for physiotherapists) in the assignment.

 

See When Are Orders, Directives and Delegation Necessary? for information on assigning and sub-delegation.

 

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I see that an order may contain a delegation. What exactly does this mean and how does it work?

When an order contains a delegation, it means that a delegation in the RHPA sense may be given by the order. For example a physician may delegate the authority to a nurse to administer energy - a controlled act not authorized to nursing - by giving an order to adjust a pacemaker. The order may be written or verbal and it may be a direct order or a directive. Regardless, the order and delegation would only be proper when performance readiness has been assured. When a verbal order is used, see the Implementer's Certification Form (Individual) for a sample record of delegation.

 

For information on how orders may contain and thus confer a delegation, see What are Orders, Directives and Delegation?. See the Medical Directive and/or Delegation Template for how this applies when a directive is used as the order.

 

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Who needs to be involved in developing a directive? Who needs to approve?

Anyone who is affected by a directive needs to be involved in its development. This includes authorizers, implementers, co-implementers (where two implementers are involved in implementing a directive, for example when a respiratory therapist decides to implement a physician's order for a lab test and a medical laboratory technologist performs the test) and individuals and groups with administrative responsibilities for practice. In smaller settings, this may be a very small number of people, for example a physician and nurse. In larger settings, the numbers would likely be much larger, and may extend to administrative groups. The extent of involvement of each party to the directive may vary depending on the nature of their responsibilities pursuant to it.

 

Directives must have the integrity of a direct order, thus all physicians or authorizers potentially responsible for patients who may receive care under a directive must approve it. Because physicians or authorizers derive their authority to give orders in part based on their professional relationship with a patient, only those with a professional relationship or anticipated relationship may approve it.

 

Larger settings with multiple physicians or authorizers may wish to consider how to best facilitate sign-off. Clarifying which physicians or authorizers are responsible for patients receiving the care that a directive applies to can be a starting point. For example, all Emergency Department (ED) physicians would be required to sign a directive applying to ED patients, and surgeons consulting to the ED who may become responsible for ED surgical patients may be involved, however an ED physician would not likely be required to sign a directive pertaining to surgery. Options for sign-off include:

  • Enabling physicians who are doing locums to sign off at the outset of the locum, or who are trainees (for example residents) to sign off during the orientation to their clinical rotation may be considered. In such instances, a review of all applicable directives with a signature on one master listing all may be sufficient.
  • For cross-hospital directives that every physician or authorizer is directly responsible for, obtaining sign-off as part of privilege renewal may be an option, as long as the timing for directive approval or renewal coincides with that for privilege renewal.

 

Implementers may sign-off on the directive, or may indicate their agreement upon implementation of it in practice. Larger settings with multiple implementers may wish to consider how to best facilitate sign-off where it is indicated. One option may be to have representative implementers sign off directly, and individual implementers may sign off upon successful completion of a program of qualification.

 

Other stakeholders to a directive may be required to sign off, depending on applicable legislation and policy governing clinical practice.

 

Involvement in and approval of a directive is addressed throughout the Guidelines and Templates, including in:

 

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At our clinic, the physicians have approved a directive for medication adjustments, diagnostic imaging, and blood tests and team members are completing prescriptions and requisitions pursuant to it. Some of our patients live out of town and will have the prescriptions filled and tests completed by the health professionals in their hometown. How can we be sure those professionals will recognize the prescriptions and requisitions as proper so that the patients will receive the care they need?

Under these circumstances, it is essential to use agreed upon formatting to signify that the prescriptions and requisitions are a physician's order, enabling the relevant professionals (in this example pharmacists, medical radiation technologists and medical laboratory technologists) to practice in accordance with their legislative requirements for orders. Any prescriptions or requisitions completed pursuant to a directive must 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. As desired, a copy of the medical directive may be forwarded to further demonstrate the integrity of the order.

 

See the Medical Directive and/or Delegation Instruction Template under the "Considerations" box of the "Documentation/Communication" section for this information. Also see the form Recommended Format For A Prescription or Requisition Completed Pursuant To A Directive for a sample completed in accordance with these requirements.

 

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What is the difference between a directive and a protocol? Can a protocol be a directive?

  • A protocol is a series of agreed upon steps for implementing a procedure, treatment or service. Protocol is a broad term and protocols may also be called care maps, care plans or policies and procedures. Protocols guide practice and the extent to which they direct and authorize practice depends upon policy within an organization.
  • A directive is a type of order necessary to permit someone to perform a procedure, treatment or service. It authorizes and directs practice in accordance with legislation requirements for orders.

In practice, directives and protocols may sometimes be used as the same mechanism, sometimes they're different, sometimes they're independent and sometimes they're used together. For example a directive may refer to a protocol as the method for carrying out the procedure ordered under the directive, such as when a directive for asthma refers to a protocol for how to administer the bronchodilators that have been ordered. Alternatively, the protocol may be linked to a direct order, or may refer to a procedure or service that does not require an order at all, for example health teaching.

 

Whenever a protocol contains an order(s) and is used to permit implementers to decide when to implement the order(s) contained within it, the protocol must comply with the requirements for a directive. (When a protocol contains an order, to avoid confusion, users may wish to consider using the term directive rather than protocol.)

 

See the Medical Directive and/or Delegation Template for how to set up a protocol when it is being used as a directive.

 

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Sometimes we get confused about when a delegation is required and what it should look like. For example, some say defibrillation requires a delegation, others say it does not because it can be performed under the RHPA emergency exception. How can we resolve this confusion?

The confusion you are describing arises from the various interpretations of delegation. It has been resolved in these guidelines by identifying the preconditions that must be fulfilled prior to authorizing and performing any procedure whether a delegation is required or not. The preconditions are as follows:

  • First and foremost, authorizers and implementers need to assure performance readiness; that is they need to demonstrate the ability to authorize and perform the procedure and manage the outcomes competently given the circumstances in the situation. Performance readiness is the basis for authority; there can be no authority to authorize or implement a procedure without competence.
  • Next, authorizers and implementers need to assure that any necessary authority, e.g., a delegation, order or setting-specific authorization such as privileges or an assignment - is in place. When the need for delegation is unclear or in dispute (as in the defibrillation example), it would be important to assure that the relevant authorizers and where applicable employers are in agreement with the practice, that an order is in place as necessary and if not, that there is a reliable means of validating agreement with performance of the procedure.
  • And finally, authorizers and implementers need to assure that in their clinical judgment the authorized procedure is warranted and in the patient's interest.

Reasonably fulfilling these preconditions indicates that authority is established. In the absence of fulfilling these preconditions, authorizers and implementers would be expected to refrain from authorizing or implementing the procedure and take the appropriate action to address patient interests. Authorizers and implementers may wish to consult with the relevant college(s) for further guidance on specific situations where the requirements for authority are in question.

 

See What Are the Steps for Authorizing and Implementing any Procedure? for identification of the preconditions and the Templates for Establishing Directives and Delegation for the optional tools for fulfilling the preconditions.

 

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When working with directives and delegation, what are authorizers and implementers accountable for?

When working with directives and delegation, both authorizers and implementers are accountable for fulfilling the preconditions identified in the Guidelines 'What Are the Steps for Authorizing and Implementing any Procedure?' and for decisions and actions taken individually and as members of team.

 

See How Does Accountability Work from a Regulatory Perspective? and What Are the Steps for Authorizing and Implementing any Procedure? for further information. The question immediately above on resolving confusion about when a delegation is required and what it looks like also addresses relevant information.

 

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Within our setting, confusion can arise regarding who is able to order and prescribe and what this means in terms of permitting others to perform procedures. How can we resolve this confusion?

The terms order and prescribe have specific legislative meaning and relevance, for example, orders and prescriptions permitting treatment may only be given and in some instances accepted by certain professionals. To minimize confusion and the potential for error, especially within multi-professional settings, it is recommended that the use of the terms order and prescribe be reserved to their legislative applications and to those with legislative ordering and prescribing authority, including audiologists, chiropodists, podiatrists, dentists, midwives, optometrists, physicians, and registered nurses in the extended class.

 

Non-ordering professionals would choose terms other than ordering or prescribing when describing their services. This may include terms such as recommending or implementing a profession-specific treatment plan. For example, in a hospital setting, dietitians may recommend an enteral diet rather than prescribe or order an enteral diet and physiotherapists may recommend or implement a physiotherapy treatment plan rather than prescribe one. When practicing under a directive, the dietitians and physiotherapists are not ordering or prescribing, they are implementing a physician's order for a dietetic or physiotherapy treatment plan. Similarly, medical laboratory technologists, medical radiation technologists, nurses, pharmacists and respiratory therapists are not prescribing tests or medication or treatment adjustments under a directive; they are implementing a physician's order for tests and adjustments.

 

See What are Orders, Directives and Delegation? for relevant information.

 

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These guidelines don't tell us exactly what procedures we can and cannot perform. Why?

The Guidelines and Templates are designed to assist authorizers and implementers to make appropriate decisions about what to do in rapidly evolving health care environments. For example the evidence about best practice treatments, procedures and technologies often outpace the ability of health regulators to define exactly what is appropriate to do. Additionally, the Guidelines and Templates recognize that the appropriateness of performing any procedure depends on the circumstances in a situation. Thus, the best people to decide what's appropriate in each situation are the health professionals who are directly involved assessing and addressing specific patient needs and interests. Explicitly defining what to do in the absence of considering the circumstances in a situation may result in inappropriate practice that puts patients and health professionals at risk.

 

This approach of supporting defined practice while enabling evolution is reflected throughout the Guide and Templates. See Why has This Guide Been Developed? for the framework that provides the foundation for the approach.

 

For more specific guidance about what may and may not be appropriate for a particular profession in a particular situation, contact the relevant College.

 

 

For more information, contact your College.

 

 

Acknowledgments

 

This guide is a consensus document developed by the Federation of Health Regulatory Colleges of Ontario. The Federation comprises the 26 health regulatory colleges that regulate health professionals in Ontario. Other stakeholders involved in the development of the guide included the Ontario College of Social Workers and Social Service Workers and the Ontario Hospital Association. For questions, contact the relevant college.

 

Federation of Health Regulatory Colleges of Ontario (FHRCO)

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