PROMOTING QUALITY PRACTICE

Controlled Acts

College of Occupational Therapists of Ontario
November 1997

Practice Scenarios:

A. I work for a Geriatric Assessment and Consultation Program where all team members are expected to complete a thorough assessment of the patients as part of a 'generic practitioner' role. This includes taking and interpreting: vital signs (e.g., blood pressure, temperature, pulse rates, etc.); heart, bowel and chest sounds; deep tendon reflexes and cranial nerves; bladder ultrasounds; audiology screening tests with an audiometer; and examining ears with an otoscope. Are any of these activities controlled acts? Can I as an occupational therapist perform these activities?

B. My work on an upper extremity clinic involves removing sutures, providing therapeutic ultrasound, debridement for burns, and occasionally splinting for a carpal fracture. I am also interested in taking a course on acupuncture. Are these services beyond the scope of occupational therapy? Is there anything to prevent me from doing them? Are any of these activities controlled acts?

C. I work in a long term care facility where I have been asked to provide collars for patients with possible unhealed cervical fractures due to osteoporosis. X-rays are not available; x-ray facilities are not present in the hospital. There is hesitancy to transfer the patients to another facility for x-rays due to the potential pain and damage from the movement. However, I don't feel I have enough information. I recognize setting a fracture is a controlled act; can I refuse a 'medical order or directive' from a physician to complete this activity?

D. In my facility there are Expanded Role Nurses whose job descriptions and hospital medical directives authorize them to order cervical collars for fractured or dislocated joints and communicate diagnostic information, both of which are controlled acts. Can I accept delegation of a controlled act or seek additional information from these individuals?

Probing Questions

1. What is a controlled act? Does occupational therapy have any controlled acts? When can an occupational therapist perform a controlled act? What is delegation of a controlled act? Who can delegate a controlled act? Can an occupational therapist refuse to complete a controlled act?

2. Are controlled acts implemented differently in sites governed by the Public Hospitals Act compared to those sites that are not governed by this act?

3. What is a directive related to a controlled act, who should develop it and where should it be kept?

Response:

RHPA
The Regulated Health Professions Act, 1991 was written so as to allow for the evolution of roles played by various health professions &SHY; to allow scopes of practice to become blurred &SHY; and to promote consumer freedom of choice. The net result was to be a more efficient, egalitarian and less costly health care delivery system. The RHPA, however, does set out in Section 27(2), controlled acts that only a member of a regulated health profession (or a person to whom a controlled act has been delegated by an authorized regulated health professional) can perform in the course of providing health services to an individual.

CONTROLLED ACTS
As set out in section 27(2) of the Regulated Health Professions Act (RHPA) and summarized in the College Briefing Note on Delegation and the Assigning of Service Components (1996) (which was included in the binders forwarded to all registrants), there are 13 controlled acts. Controlled acts are activities and procedures where risk of harm to the patient has been identified as significant.

Controlled acts can only be performed by an individual, referred to as the delegator, who is authorized to perform the act under his or her profession specific Act. No controlled acts have been authorized to occupational therapists. The RHPA does allow for a controlled act to be delegated by a delegator to an occupational therapist. Section 27 (1)(b) of the RHPA and the Draft Regulation on Receiving Delegation (1996) (included with the Briefing Note) sets out that in order for the occupational therapist to have the authority to perform the delegated act, the occupational therapist must be transferred the authority to perform the controlled act from the delegator.

As stated in the Draft Regulation on Receiving Delegation (1996), an occupational therapist should not accept delegation of a controlled act unless she has the knowledge, skills and abilities to carry out the task safely and is aware of and can manage the potential repercussions of the procedure. Registrants must recognize their areas of professional competence; accepting delegation of a controlled act confers responsibility and liability for the procedure.

An occupational therapist must refuse delegation of a controlled act if the delegator or the therapist does not meet the criteria set out in the Draft Regulation on Receiving Delegation (1996). An occupational therapist may refuse the delegation even if these criteria are met. Examples would be if the individual does not have authority under the RHPA for the controlled act (the Expanded Role Nurse, Scenario D), or the occupational therapist does not believe she or he has sufficient skills/competency or information related to the patient's condition to carry out the controlled act (long term care, scenario C).

Another individual can act as an intermediary to convey the request from the delegator to the therapist to complete the controlled act. However, the therapist must contact the delegator directly if she or he requires additional clarifying information.

SPECIFIC CONTROLLED ACTS
Therapists are welcome to call the College to clarify issues related to controlled acts. Alternatively, therapists may wish to call another College whose members have the authority to perform the authorized activity for additional information.

Within scenario A listed above, Geriatric Assessment and Consultation program, the bladder ultrasound, completed for diagnostic purposes, is a controlled act but can be delegated to an occupational therapist if it is ordered by a member of the College of Physicians and Surgeons (Ontario Regulation 107/96). None of the other activities are controlled acts.

In the upper extremity clinic, scenario B, debridement for deep burns and setting a fracture with a splint are controlled acts. Removal of sutures and providing therapeutic ultrasound are not considered controlled acts.

Within the third scenario, the occupational therapist has been transferred the authority to complete the controlled act, but must refuse to complete it until she or he confirms and can manage the required information in section 1.3 of the Draft Regulation on Receiving Delegation (e.g., the predictability of the outcome of performing the procedure, the known risks and benefits to the client of performing the procedure, etc.)

In the last scenario, the occupational therapist cannot accept delegation of a controlled act or seek additional clarifying information from the Expanded Role Nurses as these individuals do not have authority for the controlled act under the RHPA; the delegation must come from a physician, but the nurse could act as the intermediary. The therapist must seek clarifying information directly from the physician.

Many of the services listed in the scenarios above are not traditionally considered occupational therapy. However with role blurring or multiskilling, occupational therapists are becoming responsible for performing patient-related activities beyond their customary role. Prior to accepting responsibility for these activities, in keeping with the Professional Misconduct Regulation, it is the College's position that the registrant must seek out and utilize needed assistance and resources to ensure he or she can provide the quality services competently (i.e., has the competency to complete and interpret the results of the task as well as being able to manage the potential repercussions of the task).

In accordance with Standard 5 of the Standards of Practice, outcome issues related to cost-effectiveness, quality of care, and client satisfaction must be considered when evaluating these approaches to service delivery.

DIFFERENCES BETWEEN SITES GOVERNED AND NOT GOVERNED BY THE PUBLIC HOSPITALS ACT
The following will aide with distinguishing the differences: Sites Not Governed by the Public Hospitals Act: Under the Regulated Health Professions Act, 1991 (RHPA) and the Occupational Therapy Act (Bill 58), an occupational therapist is not required to have a physician's referral or medical order/directive.

However, prior to accepting delegation of a controlled act, the occupational therapist must ensure authority to perform the act has been transferred to him or her by a regulated health professional authorized to perform the act. This transfer should be documented. The College's Draft Regulation on Receiving Delegation (1996) must be followed.

Sites Governed by the Public Hospitals Act: Occupational therapists working in sites governed by the Public Hospitals Act (i.e, hospitals), must comply with this Act, as well as the Regulated Health Professions Act, 1991 (RHPA) and the Occupational Therapy Act (Bill 58). The Public Hospitals Act requires that a physician's medical order or directive is needed prior to the initiation of any treatment or a diagnostic procedure, including occupational therapy. This is often accomplished through a "medical order" or "medical directive" or "medical protocol" or "standing order" from the physician.

A medical order/medical directive/standing order is a prescription for a procedure, treatment, or intervention that may be performed for a range of clients who meet pre-specified conditions. When applicable to an individual client or client specific, it is often called a 'direct order'.

In these sites, a medical order or directive could be used by a delegator to delegate or transfer the authority to perform a controlled act to an occupational therapist. Again, the Draft Regulation on Receiving Delegation (1996) must be followed.

DIRECTIVES DETAILING CONTROLLED ACT DELEGATIONS
The Briefing Note differentiates between :

a) a medical directive or a medical order used to transfer authority to perform the controlled act from the delegator to the occupational therapist (i.e, in a setting under the Public Hospitals Act)(a mandatory action); and

b) a directive or order used to set out further detail which must be followed in performing the controlled act.

Development of a directive or order that sets out details or directions which must be followed in performing the controlled act is optional. Occupational therapists must follow any existing directives.

A directive is intended to provide guidance or parameters related to decision making when performing the controlled act. Thus each directive related to a controlled act needs to be context or situation specific.

A directive for a controlled act can be used in sites governed by legislation and requiring a physician's referral/medical directive/medical order (e.g., Public Hospitals Act) and those that are not (e.g., the community). Ideally, directives are jointly developed by the regulated health professional with the authority for the controlled act and the occupational therapist(s) to whom the act is being delegated. The directive should outline whether the controlled act is being delegated on a single case basis (delegated each time it is needed) or on an on-going basis.

The directive should also indicate whether the controlled act is being delegated to a specific occupational therapist or to a group of occupational therapists.

Appendix 5 of the Briefing Note, included with this Newsletter outlines the suggested content of a directive related to a controlled act.

Your response to this practice scenario is appreciated. Please contact Elaine Kuretzky, Director of Professional Practice, with your comments or questions:

Elaine Kuretzky
(416) 214-1177 or 1-800-890-6570
ext. 27
coto003@coto.org

* Professional Misconduct Regulation, Section 3

Relevant Reference Materials:
Briefing Note on Delegation and the Assigning of Service Components, December 1996

Draft Regulation on Receiving Delegation (1996)

Regulated Health Professions Act, 1991, S. O. 1991, c.18

Professional Misconduct Regulation, O. Reg. 800/93

Code of Ethics, 1997

Standards of Practice, 1997

Controlled Acts, Forms of Energy, O. Reg. 107/96