StandardPracticing through the Delegation of Controlled Acts

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Standard
for dietitians Practicing through Delegation of Controlled Acts


Approved by Council December 4, 2020.

Introduction

 

The College is committed to ensuring that dietitians in Ontario provide safe, quality care to clients.
 
The Regulated Health Professions Act, 1991 (RHPA) identifies fourteen controlled acts that pose significant risk of harm to the people of Ontario (View them here). If a procedure involves controlled acts that are not authorized for dietitians, then the RHPA generally permits delegations to transfer the authority to dietitians to perform a controlled act in some situations. The delegation of controlled acts in appropriate circumstances can result in more timely delivery of health care and can promote optimal use of healthcare resources and personnel.

Five Standard Statements

The five standard statements below articulate the minimum level of performance expectations for dietitians when practising through the delegation of controlled acts.
 
Performance expectations articulated in these five standard statements may not apply to every area of dietetic practice; their application will depend on client/patient factors and the dietetic practice setting. In addition to complying with the Professional Practice Standard for Dietitians Practising through Delegation of Controlled Acts, dietitians should follow organizational policies. An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario is available on the Health Profession Regulators of Ontario website.

Terminology
References
Framework  for Deciding to Practice Under Delegation

1.  Delegation of a controlled act must be in the best interest of the client/patient.

 
A registered dietitian demonstrates the standard by:

I.   ensuring a client-centered care approach;

II. making the decision to accept the delegation of controlled acts motivated by client/patient interests, e.g. improves efficiency and access to care, is more timely, convenient; and

III. not being motivated by other interests e.g. convenience of health care professional, for status or position and/or self-interest.

2.  Dietitians must have the knowledge, skill and judgement to accept a delegation of a controlled act.

 
A registered dietitian demonstrates the standard by:
 

I.    having the required knowledge, skills and judgment specific to the controlled act being delegated to safely and effectively perform the procedure;

II.   declining to perform a controlled act about which they are not knowledgeable to perform;

III.  using an evidence-based informed approach when practising through delegation of the controlled act; and

IV.  understanding that when performing a controlled act, a delegation of authority is required from someone who is authorized to perform the act by their profession-specific legislation.

3.  Dietitians must be aware of the laws permitting controlled acts to be performed in certain circumstances and when a controlled act cannot be delegated.


A registered dietitian demonstrates the standard by:

I.   being aware that dietitians must refrain from delegating authority to perform capillary skin pricks to other health care providers:

  • Because of amendments under the interdependent laws and regulations (Dietetics Act, 19911; and Laboratory and Specimen Collection Centre Licensing Act, 19902 ) 3 that have been put in place for dietitians to have the authority to perform capillary skin pricks and analyze the blood samples, it is College standard that dietitians must refrain from delegating the authority to perform capillary skin pricks to other health care providers. Students training for a profession that has controlled acts can do them under the supervision of a registered member of the profession. This would apply to dietitians training interns on techniques for skin pricking.
  1. Dietetics Act (1991): Authorized act 3.1 In the course of engaging in the practice of dietetics, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to take blood samples by skin pricking for the purpose of monitoring capillary blood readings. 2009, c. 26, s. 7​.
  2. Laboratory Specimen Collection Centre Licensing Act ,1990: “specimen collection centre” means a place where specimens are taken or collected from the human body for examination to obtain information for diagnosis, prophylaxis or treatment, but does not include, …(5.c.) a place where a member of the College of Dietitians of Ontario is engaged in the practice of dietetics… 
  3. Note that the Dietetics Act, 1991, specifies that it is within the dietetic scope of practice for dietitians to perform skin pricks. The Laboratory Specimen Collection Centre Licensing Act, 1990 (LSCCLA), specifies that when dietitians perform skin pricks while practicing dietetics, they are not considered to be specimen collection centres, and are thus excluded from the requirements (such as licensing and inspections) as outlined in the LSCCLA.

​II.   being aware of controlled acts that cannot be delegated under any circumstances:

  • For example, the controlled act of psychotherapy, as defined in the RHPA, relies upon the psychotherapeutic relationship that is established between the authorized healthcare professional and the client/patient. Delegating the controlled act of psychotherapy to someone outside of the psychotherapeutic relationship could not only reduce the quality of care and negate treatment benefits, but also present an unduly high level of risk to the client/patient.

III.  understanding that there are exceptions to the rules permitting controlled acts to be performed in certain circumstances:

  • Rendering first aid or temporary assistance in an emergency. For example, applying a defibrillator where someone appears to be having a heart attack or administering a glucagon injection when someone is suffering from a severe hypoglycemic reaction that has rendered them unconscious.

  • Assisting a person with "routine activities of living". For example, a dietitian on a home visit could, if they were competent to do so, assist clients with their regular insulin injection.

  • ​Treating a member of your own household. For example, administering substance by injection or inhalation. NOTE: Outside of the exceptions, dietitians are not permitted to treat their partner/spouse.

  • Treating a person by prayer or spiritual means if it is a tenet of the religion. For example, Indigenous Peoples in Canada can provide traditional healing services.

IV.  Knowing when a delegation is not required/necessary as dietitians already have the authority to perform the controlled act of skin pricking as authorized by the Dietetics Act ,1991;

V.   Understanding that if a procedure is not a controlled act, it is said to be in the public domain, meaning that anyone can do it. However, it could be subject to the "Harm Clause" under the RHPA or liability for civil or criminal negligence.

4.  Dietitians must ensure meeting standards for informed consent and record keeping when practising under a delegation of a controlled act.

 

A registered dietitian demonstrates the standard by:

I. ensuring clients/patients provide informed consent for the delegated controlled act, whether consent is obtained by the delegating healthcare professional or by the dietitian;

II. participating in decisions based on the client’s informed choices and health care professionals working together to make evidence-informed decisions; and

III. keeping records in an organized and systematic way that supports collaborative practice, communication, and compliance with relevant legislation.

5.  dietitians must be aware of accountability, quality assurance and delegation processes in practice settings.

 

A registered dietitian demonstrates the standard by:

I.   knowing the details of the delegation of authority required to perform the controlled act to practise safely and ensure collaborative care. Dietitians would need either a direct order or a medical directive to accept the authority to perform the controlled act. An interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario is available on the Health Profession Regulators of Ontario website;

II.  identifying that procedures and/or activities that are not controlled acts do not require delegation, but that they may still require orders depending on the practice setting. Know your organization specific policies and legislation;

III. recognizing that a work assignment and/or job description is not delegation. Another regulated health professional asking or instructing you to perform a controlled act in the moment in and of itself is not a valid delegation, or the transfer of their authority to dietitians. A delegation is always required to perform any controlled acts that dietitians are not authorized by the Dietetics Act, 1991, to do;

IV.  establishing shared understanding of the roles and responsibilities within the team for coordinating the delivery of optimal care to enable respect, trust, and shared decision-making (this is especially important when there is overlapping scope or shared authority for the performance of controlled acts);

V.   ensuring process for ongoing communication, monitoring and evaluation of the act being performed (e.g. ensuring the currency of the dietitian’s knowledge and skills);

VI. informing delegating healthcare professional of any actions taken by the dietitian to manage any adverse event(s); and

VII. being aware that the ultimate accountability and responsibility for the act that has been delegated remains with the delegating healthcare professional. Dietitians also have a professional obligation to maintain individual accountability to provide safe, competent care.

terminology


Controlled Acts

Controlled acts are activities that are considered to be potentially harmful if performed by unqualified persons. The Regulated Health Professions Act, 1991, (the “RHPA”) is the umbrella legislation that governs Ontario’s 26 health regulatory colleges and their members. The RHPA sets out 14 controlled acts, which are activities that are considered to have the potential of posing a risk of harm to patients or clients if performed by unqualified individuals. Dietitians have been granted the legal authority in the Dietetics Act, 1991 to perform only one controlled act, skin pricking, which falls within the controlled act of performing a procedure below the dermis.

Delegation

Delegation is not specifically defined in the RHPA, but it is described as a process whereby a regulated health professional who is authorized to perform a controlled act confers the authority to someone (regulated or unregulated) who is not authorized to perform a controlled act. For dietitians, delegations may be conferred by an order – direct order or directive.

Orders

An order is a direction from a regulated health professional with legislative ordering authority that permits the performance of the direction by another healthcare provider. Orders can apply to controlled acts where a dietitian is authorized to perform only with an order or public domain acts where other legislation or facility rules require an order. The Public Hospitals Act, 1990, requires orders in hospitals for controlled acts and many otherwise public domain acts. For example, despite the amendments to the Dietetics Act, 1991, which give authority to dietitians to perform skin pricks within the dietetic scope of practice, a regulation under the Public Hospitals Act still applies. As skin pricks are a diagnostic procedure, in a public hospital setting, dietitians still require an order from an authorized practitioner or a medical directive to perform this procedure. Similarly, prescribing a therapeutic diet is not a controlled act. However, most public hospitals have interpreted the diet order in a hospital setting to be “Treatment”, therefore requiring orders.

There are two types of orders:

1. Direct Order
A direct order provides instructions for an intervention or treatment to be delivered at a specific time and relates to only one client/patient. Direct orders may be oral (e.g., over the telephone, via videoconferencing, or in person) or written.

2. Directives
Directives (also called medical directives) are written orders by an authorized health care professional (often more than one) to other health care professionals that pertain to any client/patient who meets the criteria set out in the directive.

Harm Clause in the RHPA

The "Harm Clause" prohibits anyone from engaging in health care practices that would reasonably cause serious bodily harm, unless the activity is within the scope of practice of a regulated health professional. Section 30 of the RHPA outlines that the following is an offence in relation to the risk of harm provision:
 
“Treatment, etc., where risk of harm 30 (1) No person, other than a member treating or advising within the scope of practice of his or her profession, shall treat or advise a person with respect to his or her health in circumstances in which it is reasonably foreseeable that serious bodily harm may result from the treatment or advice or from an omission from them.”

By definition, no dietitian, either a general or temporary member, acting within their scope of practice, could breach the harm clause. However, dietitians causing harm while acting within their scope of practice are subject to College discipline for incompetence or misconduct and a dietitian causing harm while engaging in health care activities outside of the dietetic scope of practice, would be in breach of the harm clause, and could be prosecuted.

Scope of Practice for Dietitians

The statement is set out in the Dietetics Act, 1991, Section 3, as follows:

"The practice of dietetics is the assessment of nutrition and nutritional conditions and the treatment and prevention of nutrition related disorders by nutritional means."

Practising Dietetics

The College elaborated on the scope of practice statement to monitor competence in dietetic practise and to help with the administration of regulations, by-laws, programs, and policies, with a definition of practising dietetics:

“Practising Dietetics is paid or unpaid activities for which members use food & nutrition- specific knowledge, skills and judgment while engaging in:

  • the assessment of nutrition related to health status and conditions for individuals and populations;

  • the management and delivery of nutrition therapy to treat disease;

  • the management of food services systems; building thee capacity of individuals and populations to promote, maintain or restore health and prevent disease through nutrition and related means;

  • and management, education or leadership that contributes to the enhancement and quality of dietetic and health services.”

The College does not consider the following activities as practising dietetics:

  • Holding a position solely in non-dietetic management (e.g., Vice President or Administrator of a hospital or other organization).

  • Holding a position solely in the area of human resources (HR), information technology (IT), or risk management.

  • Engaging in sales or marketing of pharmaceuticals that are not related to nutrition.

  • Assessing facility processes to meet accreditation standards.

Unauthorized Performance of a Controlled Act

Performance of a controlled act by a person who is not authorized to perform it is a contravention of the RHPA. A person who does so is guilty of an offence under the RHPA.


REFERENCES

 

1. Dietetics Act, (1991), S0.(1991), c 26.

2. Regulated Health Professions Act, (1991). Controlled Acts, S. 27.

3. Collaborative Care Professional Practice Guidelines for Registered Dietitians in Ontario (January 2019).

4. Health Profession Regulators of Ontario. Explaining orders, directives, and delegation.

5. Collecting Capillary Blood Samples through Skin Pricking & Monitoring the Blood Readings (Point of Care Testing) Professional Practice Standard.

6. Laboratory and Specimen Collection Centre Licensing Act. R.S.O. 1990, c. L.1


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