Guidance for Health Professionals: How (Not) to Delegate

The focus of today’s blog post is the delegation of patient care by regulated health professionals. We thought this would be a good topic to touch on in light of a decision of the Discipline Committee of the College of Physicians and Surgeons of Ontario from last year in which a physician’s certificate of registration was suspended as a result her failure to appropriately delegate care to and supervise unlicensed practitioners.

Delegation of Controlled Acts

Under the Regulated Health Professions Act (RHPA), certain medical procedures, known as “controlled acts”, are considered to put patients at risk of harm if performed by unqualified individuals and are therefore restricted only to authorized regulated health professionals. Each health profession regulated under the RHPA has a scope of practice statement that describes generally what type of care the profession provides and the means by which such care is provided. As there is overlap in the scope of practice of the various health professions, some professions are authorized to perform the same, or parts of the same, controlled acts. On the other hand, there are some health professions that are not authorized to perform any of the 14 controlled acts listed in the RHPA.[1]

Under appropriate circumstances, controlled acts may be delegated. Delegation is the process by which a regulated health professional (the “delegator”), who is authorized and is competent to perform one of the controlled acts, transfers the authority to perform that procedure to someone who is not otherwise authorized by law to do so (the “delegatee”). The delegatee may or may not be a regulated health professional. In an overburdened health care system, delegation can promote interprofessional collaboration, coordinated patient care and more efficient use of limited resources.

Delegation is carried out by way of either a direct order or a medical directive. Direct orders can be written or verbal, but relate to only one specific patient. The direct order is to take place following the assessment of the patient by the delegator and provides the details necessary for the delegatee to carry out the procedure in accordance with the delegator’s professional standards. In contrast, medical directives are orders that are written in advance and provide authority to carry out a medical procedure or series of procedures for any patient where the specific circumstances and clinical conditions set out in the directive exist and are met.

Each regulated health profession has slightly different rules and regulations regarding whether delegation is permitted, which controlled acts may be delegated, and the requirements for delegating and accepting delegation. There are some common general principles regarding delegation, however, which include:

  • The best interests of the patient is the paramount consideration in all instances of delegation
  • The delegator must have legal authority to perform the controlled act, as well as the knowledge skill and judgment to perform the controlled act safely and ethically
  • The delegator must have an existing relationship with the patient for whom the controlled act will be performed
  • The delegator must be satisfied that the delegatee has the knowledge, skill and judgment to perform the controlled act safely and ethically
  • Informed consent for the performance of the controlled act must be obtained
  • The delegator must appropriately document the delegation
  • The accountability and responsibility for a delegated controlled act remains with the delegator
  • Sub-delegation is prohibited

Decision of the Discipline Committee of the CPSO

A recent decision of the Discipline Committee of the College of Physicians and Surgeons of Ontario (“College”), Ontario (College of Physicians and Surgeons of Ontario) v. Nahri, provides a vivid example of how not to delegate. The case involved a physician, Dr. Nahri, who owned her own clinic where she provided family medicine services. The staff members that Dr. Nahri employed at her clinic included international medical graduates (“IMGs”) who were not registered as physicians in Ontario. Dr. Nahri stated that she believed hiring the IMGs would enable her to provide care to a greater number of patients.

After receiving a complaint from a patient, the College launched an investigation into Dr. Nahri’s practice. The investigation revealed that the IMGs were identifying themselves to patients using the title doctor and were carrying out medical examinations, making diagnoses and providing treatment without appropriate delegation or supervision from Dr. Nahri. Through the investigation, the College also discovered that Dr. Nahri left pre-signed prescriptions pads, requisition pads and consultation requests for use by the IMGs, and permitted them to bill for the services they provided to patients using her Ontario Health Insurance Plan number. In addition, Dr. Nahri failed to obtain and document patient consent to be examined and treated by the IMGs. In her response to the investigation report, Dr. Nahri acknowledge that she had not provided adequate supervision and delegation to the IMGs, but that as a result of the investigation she had made many positive changes to her practice.

The Discipline Committee of the College found that Dr. Nahri had engaged in professional misconduct and suspended her certificate of registration for six months. The Committee explained that Dr. Nahri had not familiarized herself with her professional obligations in regards to delegation and supervision of patient care, and had therefore failed to maintain the standard of practice of the profession. These obligations include those set out in the College’s Delegation of Controlled Acts policy, which permits delegation where certain criteria are met and procedures followed, including the establishment of a physician-patient relationship, the existence of a direct order or medical directive, appropriate evaluation of the delegate’s knowledge, skill and judgment, informed patient consent, and quality assurance steps, such as appropriate supervision and documentation.

Lessons for Health Professionals

This decision serves as a reminder to all health professionals that when delegating controlled acts, the ultimate responsibility for the controlled act always remains with the delegating professional. It is critical to ensure that all instances of delegation are carried out in accordance with the regulations and guidelines set by the health professional’s College.


[1] Treatment by means of psychotherapy, which is one of the 14 controlled acts listed in the RHPA, has not yet been proclaimed and is therefore not yet in force.

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