Delegation

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disor­der as the cause of symptoms of the individual in cir­cumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis
2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth
3. Setting or casting a fracture of a bone or a dislocation of a joint
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation
6. Putting an instrument, hand or finger:
1. Beyond the external ear canal
2. Beyond the point in the nasal passages where they normally narrow
3. Beyond the larynx
4. Beyond the opening of the urethra
5. Beyond the labia majora
6. Beyond the anal verge
7. Into an artificial opening in the body
7. Applying or ordering the application of a form of energy prescribed by the regulations under the RHPA
8. Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers
10. Prescribing a hearing aid for a hearing impaired person
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or device used inside the mouth to prevent the teeth from abnormal functioning
12. Managing labour or conducting the delivery of a baby
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response
14. Treating, by means of psychotherapy technique, deliv­ered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotion­al regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning

Note that the controlled act of psychotherapy (number 14), cannot be delegated.

• Communicating a diagnosis to a patient
• Point of care testing for diabetes monitoring
• Giving an injection
• Syringing ear wax
• Collecting a nasopharyngeal or pharyngeal swab
• Performing a Pap smear
• Inserting a catheter
• Ordering an ultrasound
• Prescribing a drug
• Delivering a baby
• Allergy testing
• Psychotherapy (cannot be delegated)

• Can be written or verbal
• Pertain to a specific patient, at a specific time
• Generally take place after a physician-patient relationship has been established

• Must be written and include specific information, as outlined by the CPSO’s policy Delegation of Controlled Acts (refer to point 21)
• Pertain to any patient who meets a set of criteria specified in the directive
• Do not require the naming of specific patients

Use this checklist list to help you draft a medical directive.

Scenario

Your patient, Sam, has advanced arthritis in his hands and is unable to administer his own low molecular-weight heparin injection. He is coming into your office to receive the injection. You would like to assign this activity to your staff pharmacist; however, administering low molecular weight heparin by injection is a controlled act that is outside the pharmacist’s scope, so this requires delegation.

Delegating by direct order

You issue a direct order by writing your staff pharmacist a note asking her to administer Sam’s injection.

Delegating by medical directive

You have a written medical directive in place stating that any patient in your practice who requires a low molecular weight heparin injection will receive those injections from your staff pharmacist. When Sam calls the office to make an appointment to receive his injection, your receptionist directs him to see the pharmacist for the injection.

Choosing between a direct order or medical directive

As stated, delegation typically occurs through medical directives. If you have a controlled act that will affect a significant number of patients that you would like to assign to another team member who is not legally authorized to perform the act independently (i.e. it is outside their scope or they are an unregulated person), a medical directive is the most efficient option. Using medical directives can stream-line patients coming into your office for specific services, so that they book an appointment with the most appropriate team member from the start.

For example, if a medical directive is in place that allows physician assistants to syringe ear wax, then a patient coming in for an ear wax syringe could book to see the physician assistant instead of the physician.

Medical directives are also appropriate for ensuring patients get appropriate care in emergency situations. For example, if a medical directive is put in place to allow nurses and community paramedics to administer epinephrine for patients who are having an asthma attack, this ensures patients get the care they need.  

There will likely also be situations in your practice where you will need to use direct orders to delegate care. Not all situations where you want to delegate care will be covered by a medical directive, and in this case, you will need to use a direct order. For example, your patient, Sharon, is coming in for follow-up on her recent test results. You are off sick and you phone your office and ask your social worker if she can meet with Sharon to communicate her diagnosis in your absence. This is a direct order because it involves a specific patient, at a specific time and was given verbally.

Before deciding to delegate through a direct order or medical directive, you are accountable and responsible for ensuring:

• Your patient’s health and/or safety will not be put at risk, quality of care will not be negatively affected and the delegation serves a valid purpose (e.g. more timely or efficient care)
• Risks have been identified and mitigated (i.e. risks to patient safety)
• Delegate(s) are sufficiently supervised
• Delegate(s) have the knowledge, skill, and judgement to perform the acts competently, including managing adverse events
• Plans are in place to manage any adverse events, including having a way to communicate with the healthcare provider(s) to help with managing these event(s)

While direct orders can be written or verbal, medical directives must be written. Refer to the OMA’s checklist on drafting medical directives.

When drafting the medical directive, you must include:

• What procedure, treatment or intervention is being ordered
• Clinical conditions and situational circumstances that must exist before the directive can be implemented
• Contraindications to implementing the directive
• Who is authorizing the directive and who is implementing the directive; note that the individuals do not need to be named, but may be described by qualification or position in the workplace (for example, you don’t need to say “Jane, the registered nurse”, you could simply say “a registered nurse”)
• Effective date
• List of administrative approvals that were given for the directive, if applicable

You are also responsible for documenting any orders and referencing applicable medical directives in the patient’s medical record. For medical directives, you must document the name and number of the medical directive and that you are the authorizing physician.

During delegation, you are accountable and responsible for the patient care delivered by the people you delegate to. You must provide:

• Supervision and support proportionate to the risks. If on-site supervision is not needed based on the risks, you are responsible for providing remote consultation and help
• Way(s) to stay informed of any adverse events that may occur

If you are routinely delegating through direct orders or medical directives, you are responsible for having a reliable way to continuously monitor and evaluate delegate(s) and the delegation process itself.