Standard: Practising through the Delegation of Controlled Acts

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 practising 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.

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.