EXPLAINING ORDERS, DIRECTIVES, AND DELEGATION

 

What are orders, directives, and delegation?

When are orders, directives, and delegation necessary?

When are orders required by legislation?

Exceptions under the RHPA

 

 

 

What are orders, directives, and delegation?

Orders, directives and delegation are authorizing mechanisms used to sanction and enable performance of procedures where such sanctioning is required by law, practice convention or circumstances.

 

An order is a direction from a regulated health professional with legislative ordering authority (e.g., audiologists, chiropodists, podiatrists, dentists, midwives, optometrists, physicians, registered nurses in the extended class, and those identified in regulation) that permits performance of a procedure by another.

 

ORDERS (INCLUDES DIRECTIVES)

There are 2 types of orders:

 

Direct Orders

• Are for a specific patient upon assessment by the physician/ authorizer that the procedure is warranted.
• Are also known by other names such as prescriptions, requisitions, pre-printed orders/order sets, requests for consultation, doctor's notes and may be given as a referral for treatment.
• Are usually written but provision has been made for telephone and electronically transmitted orders (regulations under the Public Hospitals Act (PHA) and verbal prescriptions (provisions under the Drug and Pharmacies Regulation Act (DPRA). Due to the potential for error and accountability issues, verbal orders are not recommended in multi-practitioner settings when an authorizer is present and able to write the order.

 

Medical Directives

• Are given in advance by physicians/ordering authorizers to enable an implementer to decide to perform the ordered procedure(s) under specific conditions without a direct assessment by the physician or authorizer at the time.
• May authorize co-implementers, that is: one implementer may be responsible to determine when to implement the ordered procedure and another may perform it.
• Implementers are not ordering a procedure when they implement a directive; rather they are implementing a physician or authorizer's order for a procedure.
• Directives must have the integrity of a direct order, thus physicians or authorizers potentially responsible for patients who will receive care under a directive must approve it.
• Are approved only when all affected regulated professionals and relevant administrators participate in their development.
• Are always written and have essential components. See the Medical Directive and/or Delegation Template for an example.

 

In the interests of reducing confusion and margins for error, the terms order and prescribe - which are required but not defined in legislation - have been clarified to refer to a comprehensive process of commencing and managing a treatment regimen that is based upon the ability and authority to make a diagnosis, which includes taking a health history and performing a physical examination. Aspects of ordering and prescribing (e.g., adjusting and renewing medications) may be implemented under the authority of a directive from a physician or appropriate authorizer. Additionally, because the terms have legislative standing and impose specific requirements upon health care providers, use of the terms is reserved for those professionals with the legislative authority to order and prescribe (e.g., audiologists, chiropodists, podiatrists, dentists, midwives, optometrists, physicians, registered nurses in the extended class, and those identified in regulation).

Of note, an order is for a procedure, not for a regulated health professional. Regulated health professionals cannot be ordered to perform procedures and must first determine if performing the procedure is appropriate from their clinical perspective. If it is, they proceed. If not, they are expected to refrain from performing the procedure and to take the appropriate action to address patient interests.

 

DELEGATION

Delegation under the RHPA is not specifically defined, but is understood to be a process whereby a regulated health professional authorized to perform a controlled act procedure under a health profession Act confers that authority to someone - regulated or unregulated - who is not so authorized. Delegation may be conferred and established in one of two ways:

• By an order - a direct order or a directive - from an authorizer with legislative ordering authority, or
• By designation - given by an authorizer who does not have legislative ordering authority. Performance of procedures delegated by non-ordering authorizers is subject to any requirements for orders that may apply.1

 

Delegating or accepting delegation of controlled acts is subject to any applicable college guidelines, standards and regulations. Refer to the respective College for details.

 

Directives and delegation facilitate delivery and evolution of health care by extending the authority of implementers to perform procedures that evolve beyond principal expectations of practice2 at a rapid rate that often outpaces what is addressed in health profession programs of preparation and legislation. Competence to perform procedures beyond principal expectations cannot be assumed and may need to be established given the circumstances in each situation. Accordingly, the use of directives and delegation authorizing performance of such procedures is subject to more extensive performance readiness responsibilities for authorizers and implementers to ensure safe and effective care. The use of directives and delegation to extend competence and authority is only appropriate to advance patient interests, not professional self-interest (including pecuniary interest). See the Performance Readiness Assessment Template for an example of what to consider when assessing the appropriateness of using directives, delegation and performing any procedures that are beyond principal expectations.

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1 For example a respiratory therapist may delegate administration of oxygen to a physiotherapist permitting the physiotherapist to administer oxygen on condition of an order from a physician.

 

2 Principal expectations of practice (PEP) include procedures and services that are generally understood to fall within the scope of practice and authority for a profession. They include those procedures where the knowledge base and clinical practice to competently perform them is provided through entry level programs or is obtained through formal or informal education and clinical experience that expands on baseline competencies provided in entry programs. PEP are dynamic. They are based on what constitutes regular practice and evolve as a function of emerging knowledge, technologies and practices that enable a profession to address patient needs.

 

Procedures within PEP include:

• Controlled acts authorized to a profession (authorized acts) that are part of regular practice
• Procedures that are not controlled acts that fall within scope and competencies for profession

 

Procedures beyond PEP include:

• Controlled acts not authorized to the profession
• Authorized acts that are not part of regular practice
• Procedures that are not controlled acts and are not part of regular practice
• In addition, the decision to implement a procedure pursuant to a directive is initially considered beyond an implementer's PEP.

 

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When are orders, directives, and delegation necessary?

 

Orders - direct and medical directives - and delegation are preconditions required by legislation, practice convention or circumstances to authorize and permit performance of certain procedures prior to performing them.

 

Orders are required by:

• Legislation. A number of provincial and federal health statutes identify when orders are required by law to perform procedures.
• Practice Convention or Circumstances. Health care teams in some settings may use orders to coordinate and ensure appropriate care when an order is not required by law. For example, physicians may give orders for vital sign assessments or for post-operative mobilization as part of a medical plan of care. Orders from designated authorizers may also be required to qualify for certain health services and benefits.

 

Medical Directives may be used when an order is required and it is appropriate and in the patient's interest for designated implementers to implement the procedure without the authorizer's direct assessment at the time of implementation. Examples of when an order is necessary and a directive may be appropriate include authorizing dietitians to implement therapeutic diets for designated hospital patients, authorizing medical radiation technologists to administer contrast media to specific patients as part of an x-ray exam, authorizing nurses to administer analgesia to elective post-operative adult patients and authorizing respiratory therapists to adjust ventilators for patients in an ICU in accordance with conditions set out in the respective directives.

 

Delegation under the RHPA is not specifically defined, but it is understood to be required when it is deemed appropriate and in the patient's interest for someone who is not authorized by a health profession Act to perform a controlled act. For example, delegation may be used to authorize occupational therapists to splint fractures or unregulated care providers to change simple dressings in accordance with the conditions set out in the respective delegations.

 

In the interests of patient safety, sub-delegation - delegating a controlled act procedure that someone is authorized to perform by way of delegation to someone else - is not permitted. For example occupational therapists would not sub-delegate splinting and unregulated care providers would not sub-delegate simple dressings. Where performance of an act is restricted for performance under legislation other than the RHPA - for example the application of ionizing radiation is restricted to specific regulated health professionals under the Healing Arts Radiation and Protection Act (HARPA) - delegation is not mentioned, thus the authority to perform the procedure may not be delegated.1

 

Under the RHPA, there are specified circumstances called exceptions and exemptions when orders and delegation are not required where they otherwise would be. In some circumstances, a number of pieces of legislation may apply and authorization may be required in one but not another. When authorization is required in one piece of applicable legislation but not another, authorization is required. For example, the RHPA does not require respiratory therapists to have an order for tracheal suctioning, however under the Public Hospitals Act, an order is required, thus respiratory therapists require an order when performing tracheal suctioning in a hospital.

 

In addition to legislative preconditions for orders and delegation, there may be setting-specific preconditions that apply as well. For example, the authority to become involved in care and authorize or perform procedures may flow from privileges, appointments, role descriptions, care assignments, care delivery models and policies and procedures within the setting.

 

Colleges may also have relevant guidelines or regulations. Refer to the respective college for information pertaining to a specific profession.

 

1 While the term delegation in the RHPA refers to authority to perform controlled acts, it is also used in other health legislation where it refers to different matters. For example, under the Schedule of Benefits of the Ontario Health Insurance Plan, "delegated procedures" are services that physicians may bill for but have someone else perform. Such services may or may not be controlled acts. Where they are controlled acts, the RHPA provisions would also apply. In other examples, under the Public Hospitals Act (PHA) and Laboratory Specimen and Collection Centre Licensing Act (LSCCLA), administrators may 'delegate' designated aspects of their authority and responsibilities which do not include controlled acts.

 

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When are orders required by legislation?

 

Under the RHPA health profession Acts1 some professions require orders to perform controlled acts as follows:

• Dental Hygienists - require an order from a dentist to perform scaling of teeth, root planning including curetting surrounding tissues and orthodontic and restorative procedures
• Medical Laboratory Technologists - require an order from a physician, dentist, or prescribed person (e.g. nurse in the extended class) to take blood samples from veins or by skin pricking
• Medical Radiation Technologists - require an order from a physician to take blood samples from veins, administer substances by injection or inhalation, administer contrast media through or into the rectum or an artificial opening into the body, or tattoo
• Nurses - require an order from a chiropodist, dentist, midwife, physician or nurse in the extended class to perform a prescribed procedure below the dermis or mucous membrane, administer a substance by injection or inhalation or put an instrument, hand or finger beyond the opening of a body orifice. Under regulation, nurses who meet conditions may initiate certain authorized acts without an order, except where orders are required by other legislation such as the PHA and Nursing Homes Act (NHA)
• Opticians - require an order from an optometrist or physician to dispense subnormal vision devices, contact lenses or eye glasses
• Pharmacists - require an order from a dentist, nurse in the extended class, physician or person prescribed by regulation to dispense, sell or compound a drug as it is defined in subsection 117 (1) of the DPRA
• Respiratory Therapists - require an order from a dentist, midwife, nurse in the extended class or physician to perform a prescribed procedure below the dermis, intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx, and administration of a substance by injection or inhalation

 

Under other health legislation that governs practice for particular procedures,  settings or sectors, orders are required as follows:

• Public Hospitals Act (PHA). Admissions, outpatient registrations, discharges, treatments and diagnostic procedures must be ordered by a physician, dentist, midwife, or for outpatients only, an nurse in the extended class (PHA Regulation 965).
• Healing Arts Radiation and Protection Act (HARPA). Ionizing radiation must be ordered by a physician, dentist, chiropractor, chiropodist or nurse in the extended class and may only be applied by a medical radiation technologist, dental hygienist or relevant authorizer.
• Health Protection and Promotion Act (HPPA). Procedures to promote and protect public health - e.g. procurement and analysis of blood samples, immunizations, physical examinations, personal conduct, isolation, detention, facility closures, food handling - may be ordered by the Medical Officer of Health or designate.
• Laboratory Specimen and Collection Centre Licensing Act (LSCCLA). The analysis of laboratory specimens must be ordered by a physician, dentist, or as permitted by regulation a midwife or a nurse in the extended class.
• Drug and Pharmacy Regulation Act (DPRA). The compounding, dispensing and selling of drugs must be ordered (prescribed) by a physician, dentist, person prescribed by regulations, e.g. nurse in the extended class.
• Controlled Drug and Substances Act and Food and Drug Act (CDSA & FDA) (Canada). The compounding, dispensing and selling of scheduled drugs and substances must be ordered by a physician, dentist or veterinarian.
• Independent Health Facilities Act (IHFA). Orders are required in accordance with other applicable law and regulation. Failure to comply carries penalties up to revocation of license.
• Nursing Homes Act (NHA). The application of restraints must be ordered by a physician for a maximum of 12 hours per order or nurse in the extended class with physician affirmation within 12 hours; the administration of medication must be ordered by a physician, dentist or nurse in the extended class and administered by them or a nurse; oxygen must be ordered by an appropriate physician and administered by a physician or nurse; admissions are authorized by a placement coordinator.
• Patient Restraints Minimization Act (PRMA). The restraint or confinement of a patient in a hospital or facility or the use a monitoring device on such a patient must be ordered by a physician or person prescribed in regulation.

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1 Refer to the Government of Ontario E-Laws web site @ www.e-laws.gov.on.ca for the most recent version of the RHPA.

 

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Exceptions under the RHPA

 

The exceptions and exemptions under the RHPA identify specific circumstances when orders and delegation are not required for the performance of controlled act procedures. Some facilities and institutions may choose to require orders for these controlled acts as a further patient safety measure.

 

Exceptions, RHPA Section 29 (1) (2)

 

29. (1) An act by a person is not a contravention of subsection 27 (1) if it is done in the course of,

            a) rendering first aid or temporary assistance in an emergency;

            b) fulfilling the requirements to become a member of a health profession and the act is within the scope of practice of the

                profession and is done under the supervision or direction of a member of the profession;

            c) treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment;

            d) treating a member of the person's household and the act is a controlled act set out in paragraph 1, 5 or 6 of subsection 27 (2); or

            e) assisting a person with his or her routine activities of living and the act is a controlled act set out in paragraph 5 or 6 of subsection

                 27 (2).

      (2) Subsection 27 (1) does not apply with respect to a communication made in the course of counseling about emotional, social,

            educational or spiritual matters as long as it is not a communication that a health profession Act authorizes members to make. 1991,

            c. 18, s. 29.

 

Exemptions to Subsection 27(1)

Made under the RHPA, Ontario Regulation 107 - see Government of Ontario E-Laws web site @ www.e-laws.gov.on.ca for the current regulation.

 

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