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Delegation

What You Need To Know

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Delegation is the transfer of legal authority to perform a controlled act (or “procedures” involving one or more controlled acts) to an individual not authorized to perform that controlled act.

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Procedures and/or activities that do not involve controlled acts, such as those within public domain (e.g., taking vital signs or performing basic spirometry), do not require delegation, however they may still require orders depending on the practice setting.

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Delegation is a formal PROCESS that is procedure specific and may also be specific to:

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an individual patient/client;

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a specific patient/client population;

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a specific situation;

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a specific health care provider, or;

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groups of patient/client populations or health care providers.

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Ordering cannot be delegated:

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While it is permissible to delegate the performance of a procedure involving a controlled act to a health care provider (regulated or non-regulated), it is the position of the CRTO that there is no provision in the RHPA to allow a Physician or any other regulated health care professional to “delegate” the ordering of a procedure involving a controlled act to another health care provider.

What Is The Role Of Delegation In Healthcare Delivery?

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Promote patient safety

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Facilitates access to care

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More timely and/or efficient services

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Improvement in the use of resources

Authorized Acts

The controlled acts authorized to Respiratory Therapists in the Respiratory Therapy Act, 1991 (RTA) are:

In the course of engaging in the practice of respiratory therapy, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to perform the following:

    1. Performing a prescribed procedure below the dermis.
    2. Intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx.
    3. Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx.
    4. Administering a substance by injection or inhalation.
    5. Administering a prescribed substance by inhalation (this is specific to Oxygen)

The RTA requires an order for all controlled acts authorized to Respiratory Therapists (regardless of practice setting) except* for:

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suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx; and

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Administering a prescribed substance by inhalation.

* Please note that, depending on the practice setting, other legislation may require an order even for these acts (e.g., the Public Hospitals Act).

If you have terms, conditions or limitations prohibiting you from performing any respiratory therapy procedures that involve controlled acts, you cannot accept delegation for those procedures. (See CRTO Policies: Graduate Certificate of Registration; Supervision Policy; Inactive Certificate of Registration Policy)

Did You Know?

The RTA states that the legislated scope of practice of RTs is:

The practice of respiratory therapy is the providing of oxygen therapy, cardio-respiratory equipment monitoring and the assessment and treatment of cardio-respiratory and associated disorders to maintain or restore ventilation.

RTs may only accept delegation for certain controlled acts while acting within their scope of practice.

Registered Respiratory Therapists with an Active Certificate of Registration (with no terms, conditions, or limitations):

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Can delegate

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Can accept delegation

Graduate Respiratory Therapists:

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Cannot delegate

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Cannot accept delegation

Student Respiratory Therapists:

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Cannot delegate

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Cannot accept delegation

Did You Know?

Terms, Conditions and Limitations (TCLs) and Student Respiratory Therapists

An RT with TCL’s on their Certificate of Registration must be aware of their exact limitations and not accept delegation for procedures they are not permitted to perform. For example: If you decide to suction a patient and there is a limitation on your certificate preventing you from suctioning, then you cannot go ahead and accept delegation to suction.

Student Respiratory Therapists who were permitted to perform advanced prescribed procedures below the dermis (under an exemption in the RHPA), are no longer permitted to perform advanced prescribed procedures once they become GRTs. GRTs are not permitted to accept delegation for these controlled acts (See Registration and Use of Title PPG and Certification Programs for Advanced Prescribed Procedures below the Dermis PPG)

Did You Know?

Authorizing Mechanisms – Orders and Delegation

  • RTs do not require delegation to perform authorized acts 1, 2 and 4 – but still require an order or medical directive to proceed. (see Interpretation of Authorized Acts PPG and Orders for Medical Care PPG)
  • RTs performing procedures involving delegated controlled acts (e.g., allergy testing) also require a valid order or medical directive to proceed. (see Orders for Medical Care PPG)
  • The Health Profession Regulators of Ontario (HPRO) has published interprofessional guides, tools and templates to assist regulated health care professionals to develop processes for delegation and the use of medical directives. The aim of these tools is to meet all the regulated professional standards of practice (Home | HPRO (regulatedhealthprofessions.on.ca))

What Is Not Delegation?

An assignment of responsibility and/or duties is not delegation. Even if you are “assigned” to care for patient/client(s) by your supervisor (e.g., a physician, midwife, nurse practitioner or dentist) you would require proper delegation (and orders) to perform any specific procedures involving controlled acts that are not authorized to you. Another regulated health professional asking or instructing you perform a controlled act in the moment, does not constitute the process of “delegation” or the transfer of their authority to you.

“Assisting” a regulated health professional to perform controlled acts does not mean that his or her authority to perform the controlled act has been transferred to you. In this case you are only assisting with the procedure and do not require delegation.

Teaching someone to perform a controlled act (e.g., a regulated; non-regulated health care provider, or other caregiver) may not be enough. Delegation is a process. For more information regarding the standards of practice of teaching versus delegation and a variety of common practice scenarios, please refer to the Responsibilities of Members as Educators PPG.

When Is Delegation Not Required?

If the procedure is not a controlled act, it is in the public domain and delegation is not required. In this case, you may perform the procedure provided you have the competency to perform it. Depending on your practice setting you may require an order to proceed.

Did You Know?

Public Domain

  • Administering an oral medication is not a controlled act and does not require delegation; however, administering an oral medication does require an order or a prescription in most practice settings.
  • Performing spirometry is not a controlled act and does not require delegation but does require an order in a hospital or pulmonary function testing (PFT) laboratory.

RHPA Exceptions

If a procedure involves a controlled act and you do not have the authority to perform it (i.e. the procedure is not one authorized to Respiratory Therapists), you may perform the controlled act in one of the following exceptions allowed by the RHPA [as listed and numbered in the RHPA]:

Exception #1

Giving first aid or temporary assistance in an emergency.

You may perform a controlled act in giving first aid provided you have the competency (knowledge, skills and judgment) to perform the procedure.

If a Respiratory Therapist faces an emergency situation, they should not let fear of prosecution for performing a controlled act hinder their response. The CRTO also encourages Respiratory Therapists and their employers who face emergencies on a regular basis to proactively develop policies and procedures, guidelines, processes for delegation and medical directives to help guide their response. (e.g. The use of AED’s in a facility where it is anticipated that the RT’s will be required to participate as a first responders should have a formal delegation process for that controlled act, which includes education and training) These documents may also serve to provide evidence of competency training and ongoing quality assurance to support the practice of Respiratory Therapists in emergent situations.

Exception #2

Fulfilling the requirements to become a member of a health profession and the controlled act is within the scope of practice of the profession and is done under the supervision or direction of a member of the profession.

Student Respiratory Therapists do not require delegation to perform controlled acts provided they are enrolled in a CRTO approved program to become Respiratory Therapists AND the controlled acts are within the scope of practice AND a Member of the CRTO is supervising or directing them.

Exception #3

Treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment.

If you are performing a controlled act in treating a person by prayer or spiritual means in accordance with the principles of your religion you do not need to have the act delegated to you.

Exception #4

Treating a member of the person’s household and the act is controlled act 1, 5 or 6 (as numbered in the RHPA); and, the acts that may be performed when treating a member of your household are:

  1. Communicating to the member of your household, or their personal representative, a diagnosis identifying a disease or disorder as the cause of symptoms of the member of your household, in circumstances in which it is reasonably foreseeable that the member of your household, or their personal representative, will rely on the diagnosis.
  2. Administering a substance by injection or inhalation;
  3. Putting an instrument, hand or finger;
    • beyond the external ear canal,
    • beyond the point in the nasal passages where they normally narrow,
    • beyond the larynx,
    • beyond the opening of the urethra,
    • beyond the labia majora,
    • beyond the anal verge, or
    • into an artificial opening into the body.

Exception #5

Assisting a person with their routine activities of living and the act is controlled act 5 or 6 (as numbered in the RHPA). The acts that may be performed when assisting an individual with their activities of daily living are:

  1. Administering a substance by injection or inhalation;
  2. Putting an instrument, hand or finger;
    • beyond the external ear canal,
    • beyond the point in the nasal passages where they normally narrow,
    • beyond the larynx,
    • beyond the opening of the urethra,
    • beyond the labia majora,
    • beyond the anal verge, or
    • into an artificial opening into the body.

These exceptions mean that a person is not in contravention of the RHPA if they perform the controlled acts under the exceptions listed above.

A Few points to consider…

As a member of the CRTO, you will be held to the expected standards of practice of the CRTO and the profession in your performance of a procedure, even if it is performed under the exemptions allowed by the RHPA.

Delegation is not required/necessary when a regulated health professional already has the authority to perform the authorized controlled act.

 

  • E.g., It is not necessary to delegate oxygen therapy administration to a registered Physiotherapist in a hospital setting. Physiotherapists are authorized to perform the controlled act administering a substance by inhalation in the Physiotherapy Act.

When Is Delegation Required?

In all practice scenarios not covered by the “public domain” or included in the RHPA “exceptions”, the authority to perform a controlled act other than the acts authorized to Respiratory Therapists MUST come from delegation from another competent, regulated health care professional who has the authority to perform the controlled act and who is not prohibited from delegating the procedure by their specific College.

Can I Accept Delegation Of Procedures?

Yes, you may accept delegation of controlled acts not authorized to CRTO Members under the RTA when all of the following conditions are met:

  1. You reasonably believe that the delegator has the authority and competence to perform and to delegate the controlled act. In other words, you have no reason to believe that the delegator is not permitted to delegate the controlled act; and
  2. You have the authority to perform the controlled act safely, effectively, competently and ethically. In other words, you have no terms, conditions or limitations on your certificate of registration which may prohibit you from performing the delegated controlled act; and
  3. You have the competency to perform the controlled act. In other words, your competency to perform the delegated controlled act has been confirmed either directly or indirectly by a regulated health care professional who is also competent and has the authority to perform the procedure; and
  4. You have determined that receiving delegation of the controlled act is appropriate giving due consideration to:
    1. the best interest of the patient/client
    2. the known risks and benefits of performing the procedure for the patient/client(s),
    3. the predictability of the outcomes of performing the procedure,
    4. the patient/client’s wishes,
    5. the safeguards and resources available in the situation; and
    6. other elements specific to the situation.

When making the decision to accept delegation to perform a controlled act that is not authorized to you under the RTA, you are reminded that authority alone is not reason enough to perform the procedure. You must have the competency to perform the delegated procedure and most importantly, performing the procedure must be in the patient/client’s best interests.

PLEASE NOTE:

Graduate Respiratory Therapists (GRT) are prevented by the terms, conditions and limitations on their certificate of registration from accepting delegation for any controlled act. (e.g communicating a diagnosis).

Who Can Delegate To Me?

As specified in the RHPA, a Regulated Health Professional with the authority to perform a controlled act is the only person who may delegate a controlled act. (e.g., delegation cannot be received from a committee). It is possible for more than one profession to have the authority to perform and delegate the same controlled act.

You must not accept delegation from individuals who themselves have received delegation to perform a controlled act procedure. For example, you cannot accept delegation as the authority to perform the controlled act of administering a form of energy (defibrillation) from an unregulated health care provider. E.g., EMS paramedic, who has received delegation from a physician to perform the procedure. In this scenario, the paramedic, does not have the authority to delegate a controlled under the RHPA. Further, delegated controlled acts may not be delegated over again to another person. This amounts to the concept of “sub-delegation” which is not permitted.

Accepting Delegation Decision Flowchart

What Are My Responsibilities When I Accept Delegation?

You are responsible for the performance of the procedure to the standard of the profession of the delegator or the generally accepted standard of practice of health care practitioners providing similar care. In other words, you must have the requisite competency (knowledge, skills and judgment) to perform the procedure before you accept delegation.

You should also maintain proper documentation of your actions by keeping a record of what activities you accepted delegation and who delegated the activities to you. The preferred method of doing this is to keep records of delegation (and other professional development) in your learning log and Quality Assurance (QA) Portfolio Online for Respiratory Therapists (PORTfolioOM). Your competency records regarding delegation should include the following:

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the regulated health care professional (e.g. physician) who has delegated the controlled act;

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the controlled act that have been delegated to you;

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continuing education related to the delegated controlled act; and

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the period of time that the delegation remains in force prior to requiring reconfirmation of ongoing competence in the procedure. (e.g. an organizational requirement that the delegation you receive to perform defibrillation may be time-limited to one year or the expiry date of your ACLS certification , at which time you must once again demonstrate competence in the procedure).

Remember that just because you can accept delegation doesn’t necessarily mean that you should accept delegation. CRTO Members must consider whether it is appropriate, safe, and ethical and in the best interest of the patients/clients that you are caring for.

Most employers will have policies and procedures regarding delegation detailing their process for giving and receiving delegation. You should check your employer’s policies before accepting delegation. Your employer may also have specific requirements regarding documentation when you accept delegation to perform a controlled act procedure. For more information regarding documentation obligations, please see CRTO’s Documentation PPG (crto.on.ca)

GLOSSARY

Authority the right to act – usually related to jurisdiction provided in a statute or to terms, conditions or limitations imposed on a certificate of registration – individually specified (by a panel) or related to an entire class of certificates of registration (specified by Council or a panel).

Authorized Act is a controlled act, or portion of a controlled act, that is authorized within a health profession act for a health professional to perform [there are four acts authorized to Respiratory Therapists by the Respiratory Therapy Act, that are created from three controlled acts defined in the RHPA]; the controlled acts authorized to Respiratory Therapists are:

    1. Performing a prescribed procedure below the dermis;
    2. Intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx;
    3. Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx;
    4. Administering a substance by injection or inhalation; and
    5. Administering a prescribed substance by inhalation.

Controlled Act one of the following 14 acts defined in the RHPA [section 27(2)] when it is performed “with respect to an individual”:

    1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
    2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
    3. Setting or casting a fracture of a bone or a dislocation of a joint.
    4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
    5. Administering a substance by injection or inhalation.
    6. Putting an instrument, hand or finger,
      1. beyond the external ear canal,
      2. beyond the point in the nasal passages where they normally narrow,
      3. beyond the larynx,
      4. beyond the opening of the urethra,
      5. beyond the labia majora,
      6. beyond the anal verge, or
      7. into an artificial opening into the body.
    7. Applying or ordering the application of a form of energy prescribed by the regulations under this Act.
    8. Prescribing, dispensing, selling or compounding a drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
    9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
    10. Prescribing a hearing aid for a hearing impaired person.
    11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
    12. Managing labour or conducting the delivery of a baby.
    13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
    14. Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception, or memory that may seriously impair the individual’s judgement, insight, behavior, communication or social functioning.

Competence having the requisite knowledge, skills and judgement to perform the procedure.

Delegatee the person receiving the authority to perform a procedure.

Delegator when the patient/client is apparently experiencing severe suffering or is at risk, if the procedure or treatment is not administered promptly, of sustaining serious bodily harm.

Emergency the person conferring the authority for another to perform a procedure.

Forms of Energy the following forms of energy are prescribed in regulation:

    1. Electricity for,
      1. aversive conditioning
      2. cardiac pacemaker therapy
      3. cardioversion
      4. defibrillation
      5. electrocoagulation
      6. electroconvulsive shock therapy
      7. electromyography
      8. fulguration
      9. nerve conduction studies, or
      10. transcutaneous cardiac pacing
    2. Electromagnetism for magnetic resonance imaging
    3. Soundwaves for,
      1. diagnostic ultrasound, or
      2. lithotripsy

HPPC Health Professions Procedural Code – RHPA; Schedule 2.

Member a member of a regulatory college under the RHPA.

Reasonably sensible, rational often referred to as the reasonable person test – determined by case law – in the case of the CRTO, a panel would determine whether or not an individual, giving consideration to all circumstances, acted in a sensible, rational manner in the matter under discussion.

Respiratory Therapist a Member of the CRTO (refers to RRT, GRT, PRT, Inactive Member).

RHP / Regulated Health Professional a health care provider who is a member of a College and is regulated by the RHPA (e.g., nurse, physician, dentist, massage therapist, physiotherapist, dietitian, occupational therapist, etc).

RHPA Regulated Health Professions Act, 1991.

RTA Respiratory Therapy Act, 1991.

REFERENCES & LEGISLATION
REFERENCES

College of Nurses of Ontario (2020). Practice standard: Decisions about procedures and authority. Retrieved from https://www.cno.org/globalassets/docs/prac/41071_decisions.pdf

College of Physicians and Surgeons of Ontario (2021, March). Delegation of controlled acts. Retrieved from https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Delegation-of-Controlled-Acts

College of Respiratory Therapists of Ontario (2020, March). Professional practice guideline: Interpretation of authorized acts. Retrieved from https://interpretation.crto.on.ca

Health Profession Regulators of Ontario. An Interprofessional Guide on the use of Orders, Directives and Delegation for Regulated Health Professionals (2021). Retrieved from: http://www.regulatedhealthprofessions.on.ca/orders%2c-directives%2c-delegation.html

 

LEGISLATION

Regulated Health Professions Act, 1991. (see s.27)
www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r18_e.htm

Respiratory Therapy Act, 1991. (see s.4)
www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r39_e.htm

Prescribed Substance Regulation O. Reg. 596/94: GENERAL (ontario.ca) (see Part VII.1)
www.ontario.ca/laws/regulation/940596