COTO
PROMOTING QUALITY PRACTICE

Transparent Practice

College of Occupational Therapists of Ontario
February 1999

Transparent practice is clear, open, thorough communication with all stakeholders in all circumstances related to all aspects of practice. (Guiding Principles of Practice, definitions) The College receives numerous practice calls about a variety of situations that pose some dilemma for the therapist. Although the scenarios differ greatly and the College policies to be considered may vary, there is one policy which can by applied in the majority of these situations - the need to ensure transparent practice. The following scenario demonstrates this need well.

Practice Scenario
An OT in a rural northern community has an independent private practice and provides services related only to the Assistive Devices Program. She receives a referral from a vendor to assess and prescribe a wheelchair for a client who lives in a home for the aged and has been deemed not capable of making a treatment decision (Health Care Consent Act). The client has a son, living in the nearby community, who is actively involved in the care of his mother, and is the substitute decision maker.

Probing Questions
  • How does transparent practice apply in this situation?
  • Who are the relevant stakeholders?
  • What responsibility does the OT have in communicating with all stakeholders?
Issues to Consider
In order to support the principle of transparent practice, the therapist must first define who the stakeholders are, what the purpose and extent of the service requested is, and the intervention required. Even before initiating service the OT must assess her/his ability to respond to the request. It is not possible to communicate clearly those things that one is not aware of. The process must start with a review in the therapist's own mind of all the factors involved. The therapist is then in a position to facilitate open and honest communication with the client(s). This should include consideration of the therapist's own interests, and, if determining that they impact on the situation in any way, addressing them openly with the client.

As stated in the Guiding Principles of Practice, the College recommends that this process begin immediately ­ at or before the initial meeting with the client. Communication should include, but not necessarily be limited to information about:
  • the scope of the referral and service to be provided,
  • the potential benefits and limitations of the OT service,
  • details of payment for the service,
  • consent and confidentiality issues,
  • record keeping information, including to whom verbal and written reports will be shared,
  • professional credentials and accountabilities.
It is the therapist's responsibility to initiate a process that supports transparent practice with each client. Not only will this help to avoid any misunderstandings later on; it will help the therapist to establish a trusting and respectful relationship with the client. Open and honest communication is a key element in demonstrating integrity with your client. In the Guiding Principles of Practice it also states that the therapist must not misrepresent their role or competence to the client. In order to avoid any inadvertent misrepresentation it is important to provide the client with a clear understanding of the scope of the referral and intervention proposed to meet the request for service. Therapists should also inform clients of their accountability to the College, and if requested, provide College documents and information about how to contact the office.

Open discussions about the involvement and role of other stakeholders is also critical early in the process. In a situation where there are multiple clients, a communication plan which the client agrees to and understands the importance of, is recommended. The therapist must discuss the benefit of such a plan with the client and clearly determine the extent and type of information to be discussed with each person. While it is important to communicate with all stakeholders, the therapist must carefully consider confidentiality issues and ensure that the client has sufficient information to provide informed consent for the sharing of appropriate information.

As the therapeutic relationship develops and intervention proceeds, the therapist must continue to maintain open communication with the client(s). New information may require a change from the original plan. The client and relevant stakeholders must be informed. The therapist may need to recommend or refer the client to other services as the client's needs and interests dictate. As the process concludes, the therapist must complete the communication process and ensure that the primary clinical client is aware of the OT conclusions, opinions and recommendations arising from the assessment and intervention, unless the information is considered harmful to her/him.

Response to Scenario
In the scenario above there are several clients and the therapist must distinguish the needs of each. The primary clinical client has been deemed not competent and therefore the therapist must first determine who the substitute decision maker (SDM) is. This person serves not only as a decision maker, but also as a representative of the client's needs and desires. This individual should be clearly identified to all stakeholders. The SDM in this case is identified, but this should be verified in each case. Regardless of who the SDM is, the role of the family should be considered separately. Do they visit often? To what extent do they assist with care of the client? Does the client visit outside of the home with them? Answers to these questions may impact on the needs of the client.

The client also lives in a home for the aged and thus a liaison should be established within the facility in order to promote clear communication and expectations with staff. Ideally this will be a consistent person who will coordinate communication with other facility staff as necessary. This will help ensure that staff is clear about their role in the provision of service and that they understand who to contact with any questions or concerns. A clear communication path with staff will also encourage any additional and necessary information to be shared with the therapist, thereby allowing the therapist to best meet the client's needs.

The vendor of the wheelchair is an additional stakeholder who needs to be informed of the therapist's and client's expectations and needs. Their role will be critical to the successful outcome of the OT service. The therapist should also inform the vendor of the lines of communication in order to ensure accurate flow of information.

The principle of transparent practice is quite straightforward and implementation is not difficult. It does however require a comprehensive and intentional approach. As therapists become conscious about applying the principle of transparent practice, the process involved becomes a routine component of practice.


Resources:
  • College - Guiding Principles of Practice - Section 6 Transparency, 1998
  • College Standards of Practice, 1996
  • College Code of Ethics, 1996
  • College - A Guide to the Health Care Consent and Substitute Decisions Legislation for Occupational Therapists, 1996